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_A 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 /> r�\ THIS PERMIT EXPIRES 1 YEAR FRONT. DATE ISSUED Date Issued 12-1,2472- <br /> �U (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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joagin Local%�ealth' Distrjc . <br /> JOB ADDRESS/LOCATION o �s S^�. ,� � � CENSUS TRACT `�6 <br /> Owner's Name �� Phone `3 4 5'-3 o 3 <br /> Address Go ,6 � � ,� �(; City <br /> _ o <br /> Contractor's Name License #cjL1 �-Phone&,g7-4/eyo <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /_/ RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/.;r'PUMP REPLACEMENT /-7 <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 /> ,-'Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout c^ <br /> Other Other Information yj <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. X20/fp <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /77 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 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 /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ,�c <br /> APPLICATION ACCEPTED BY ��/'2� .Til DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE /-/_ •' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M W`� <br />