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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORF�FICE USE: J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z&Vf L/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ±--2 1-79 , <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 Pand the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �? c��� CENSUS TRACT <br /> Owner's Name Phone <br /> Address city <br /> Contractor's Name (-73,3 License #—)ePU-1f-fb1Phone � <br /> 04lv1-3- <br /> TYPE OF WORK (Check) NEW WELL/-7 DEEPEN /-7 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 C <br /> G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. .f <br /> PUMP REPLACEMENT: State Work DonecS? T <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 /> information is true to the best of my knowledge and belief. 'ja <br /> SIGNED TITLE a-2 Zi <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS PECTION PHASE I INSPECTION <br /> INSPECTION BY "Rim — INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />