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_ jU :SE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROOFFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 3 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q- ?2.7,z <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 <br /> Owner's Name ( / ` G'N 3 -% . <br /> Address t 43 �? ive City IC�G��e' <br /> Contractor's Name -4 �=/� &I J' l'(` . License # 246(2 Phone (s-J-077 <br /> TYPE OF WORK (Check): NEW WELL /1q DEEPEN j / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK p 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 j z <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 /> informat true to the best of my knowledge and belief. <br /> SIGNED ,� r �- � ' TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDE <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY AA DATE 2—Z7—Z _--- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRPHAS NSPECTION <br /> VV9CT)FON <br /> INSPECTION BY - ATE INSPECTION BY ti ATE 7,- <br /> CALL <br /> cCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br /> :k <br />