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�J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ - 7 V 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2.:,1�71--, <br /> (Complete In Triplicate) <br /> Application is hereby mad 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 /> JOB ADDRESS/LOCATION ��" J\J\ d` �t- ��' CENSUS TRACT v y <br /> Owner's Name Phone <br /> Address 4 ,� a a City <br /> Contractor's Name I � � �� License3 _ 7 <br /> ct G Phone7V� '/ �/ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/-7 RECONDITION /—T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ---- Cable Tool Dia. of Well Excavation <br /> —=--liGmestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J z <br /> Irrigation Gravel Pack Depth of Grout Seal C>. <br /> Other Rotary Type of Grout '> -;a N�-j �- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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 -: -%,L TITLE �-� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 - <br /> ADDITIONAL <br /> "ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE >-a2- `f "_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Imo► <br /> E H 1426 4/72 1M <br />