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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. P0 <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION «- CENSUS TRACT Sj <br /> Owner's Name L_ Phone '.7d^�3 O <br /> Address VA n rl'd City <br /> Contractor's Name License # 04%0 Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN" _7 RECONDITION /7 DESTRU €�f <br /> PUMP INSTALLATION / PUMP REPAIR'/ / PUMP REPLACEMENT 1 T <br /> Ot r <br /> DISTANCE TO NEAREST: SEPT TANK SEWER LINES PIT PRPVY <br /> S IEM CESSPO / PAGE PI _ 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information f- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump V <br /> P• <br /> • <br /> PUMP REPLACEMENT:/ State Work Done <br /> PUMP REPAIR: LU State Work Done <br /> ,pESTRUCTION OF WELL: Well DiameterymgWM&0-eX1 Approximate Depth <br /> Describe Mater al 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 /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2,2:2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III 'FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _f,r? _ DATE /`2 -a2 o <br />` CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI„N. *4 <br /> E H 1426 4/72 IM <br />