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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.,,-.Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z-37 <br /> THIS PERMIT EXPIRES l 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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Jo quin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION / Y:<' <br /> �/ (. /� ( }� E <br /> / F <br /> Owner's Name /c ��� �.� Phone �� - _r- <br /> Address U �� � , ' c" �' � City <br /> = _ - t.f..r ic <br /> Contractor's Name ' ' c r_ � License Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/-7 RECONDITION / 7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION /r/ PUMP REPAIR J / PUMP REPLACEMENT 7 <br /> Other /-7 <br /> 7TH <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> oQ <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 /> 1 <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 /> ,pESTRUCTION OF WELL: Well Diameter <br /> 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 <br /> the bgat of my knowledge and belief. <br /> SIGNED h': 1 /�` (, a TITLE <br /> (RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASA 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. 1 <br /> E H 1426 4/72 iM <br />