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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE� USE: 1601 E. Hazelton Ave. '"Stockton, Calif. <br /> Telephone: (209) 466=6781_, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP�''PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ba e� ss.ued _/eo_Tf— <br /> Applicationis- hereby made to the. San (Joapq uin Local rHplicate)Districtealth <br /> o costrct <br /> and/or install the work herein described. This application ismade `inrcompliancetwithnSanuJoaquin <br /> County Ordinance No. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS11LOCATION1 <br /> CENSUS TRACT _ <br /> Owner's Name ) Phone -^� <br /> Address <br /> {..,. <br /> Cit <br /> It Y � � . <br /> Contractor's NameE�C �- moo License ; '' o `' <br /> i --- �a Phonep</ � <br /> h <br /> TYPE OF WORK (Check): NEW WELL / / -DEEPEN /_% RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CI+� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigaition Gravel Pack Depth of Grout Seal <br /> Other j Rotary Type of Grout <br /> Other Other Information <br /> I <br /> t <br /> PUMP INSTALLATION: Contractor 41 �, <br /> I Type of Pump r - H.P. f <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:-1 / / State Work Done <br /> DESTRUCTION 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 notifthem before <br /> Y putting the wel] in use. The above_ / <br /> Lnformation is true to a best of my knowledge and belief. ✓ <br /> aIGNED <br /> ��:�•� TITLE <br /> 4-_Z7� <br /> / (D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?HASE I I ' <br /> LPPLICATION ACCEPTED BY BATE <br /> LDDITIONAL COMMENTS: <br /> "PHASE II GROUT INSPECTION PHASE III/FIWAL INSPECTION <br /> ENSPECTION BYI DATEINSPECTION BY DATE 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION// <br /> E H 1426 7/72 1M <br /> x <br />