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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL�6;71/ <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> ` Phone ��� �•�� <br /> Owner's Name <br /> " city <br /> .Address `7 / <br /> License <br /> Contractor's Name Phone.4 •/ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION & DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST SEPTIC TK S PIT PRIVY <br /> SEWAGE DISPOSAL FIELDMER LINECESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing / �1-" V <br /> Domestic/private <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 /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: �/ <br /> State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> ct <br /> I hereby agree to comply with all laws and regulations °wellthe <br /> construction.LOWithinaFIFTEENtDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on new and well, Ithemlbeforesputtingfurnih the athe owell nLocal in use. rict a <br /> wilbove <br /> WELL DRILLERS REPORT of the welly <br /> informatio is true to thebestof my knowledge and belief. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ¢ "76 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: pig FI INSPECTIO <br /> PHASE II GROUT INS CTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N• 4/72 1M <br /> E H 1426 <br />