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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> iA Telephone: (209) 466-6781 <br /> 00 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71oP <br /> 1 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /372 <br /> J (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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION P%rjDj0Atkdj4a,*.* YV A4t1* &,p-t C A-rW-, CENSUS TRACT <br /> Owner's Name l� 4�: t t t rt ac_ Phone <br /> Address e�0/` ' Y"+r9+ �1 !�?+ City <br /> Contractor's Name Ad c '"-z License �i j 'phone � ?„ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR �/ PUMP REPLACEMENT /7 S~ <br /> Other /-7 _ kri <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0 <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 ay <br /> Irrigation Gravel Pack Depth of Grout Seal C <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor '7 10 "' <br /> —QISType of Pump H.P. pcd <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 /> information is true to the best <br /> of <br /> my knowledge an belief. <br /> SIGNED eE l �C! TITLE <br /> DRA PLOT PLAN ON ERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE %Q �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION rECTION. <br /> I FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION B DATE 7/ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 7/72 1M <br />