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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> Ir PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> r \, THIS PERMIT EXPIRES 1 YEAR FROM DAT., TSSUED Date Issued' <br /> kAvi t) (Complete In Triplicate) <br /> Application A 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 R?egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T.shar rtan <br /> m . . gide of � y1�,}gG>--Wes A�w&kada CENSUS TRACT <br /> Owner's Name PrIq+.h Rnp; Phone <br /> Address p-0- Aox 3H8✓ City <br /> Contractor's Name eA„ .TnA,,,zi� p�,mio C psr License # Phone 3C9-8471 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /—T <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /77 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G� <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <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 /> ,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 est of my knowledge and lief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY R� ;%..1 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 <br />