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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: r 1601 E. Hazelton -Ave. ; Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> 4-36 ADPL CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?- <br /> THIS <br /> ZTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-7 L <br /> 1 11 (Complete In Triplicate) <br /> Application is here . 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 _Ctb� , IVIr bW CENSUS TRACT <br /> Owner's Name Mrf C J r N G. Phone l�,LtZ-7-74�$�o <br /> Address �e �� �1 uY City s .. <br /> Contractor's Name ( —��_ License # 4fa7,1Vhone A1,747 <br /> � <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN j / RECONDITION /-7 DESTRUCTION /- <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 /> 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 S '' ©► <br /> Type of PumpH.P. o filS. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 12&#Zl1 <br /> ohJmr <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 C <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 m owle ge,and "b ief <br /> SIGNED E <br /> ( W OT AN ON REV SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -�-- _ l C''L ._ DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION s <br /> E H 1426 4/72 1M C <br />