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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FGR OF M E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : ' (209) 466-6781 <br /> �f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 <br /> I N <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED Date Issued W-36-73 <br /> . (Complete. In Triplicate) <br /> Application is hereby made to the�San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in Compliance with San Joaquin <br /> County Ordinance No., 1862 .and the Rules and Regulations of the San- Joaquin Local Health District. <br /> �. ..-Y - -�� ,. M�7— 31-0-0.6 <br /> JOB ADDRESS/LOCATION , ' CENSUS TRACT <br /> Owner's Name AD Phone <br /> Address _ i : City <br /> Contractor's Name License 9E .2a Phone &� Jr 9-" <br /> 3(�- 73"7[) <br /> TYPE OF WORK (Check) : NEW WELL /R/ DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> _ Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS m <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �X Domestic/private Drilled Dia. of Well Casing 14 ►' �' <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack. Depth of Grout Seal �� 5 <br /> Other 1 Rotary Type of Grout �prn��►. _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type�of Pump R.P. <br /> PUMP REPLACEMENT: A_/ / State Work Bane <br /> __. <br /> PUMP REPAIR- / / State Work Done <br /> . ?ESTRUCTION OF WELL: Well Diameter '� - - -` Approximate-Depth - - --- <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new_ well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> } SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE eAj27 <br /> ADDITIONAL COMMENTS: <br /> PHAU 11 G OUT- INSPECTIO PHAS III/F NAL INSPECTIO <br /> INSPECTION BY DATE 9 P-4,17INSPECTION BY DATE01 <br /> 3 <br /> CALL FOR A GROU INSPECTION PRIa TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 7/72 1M ' <br />