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f� SjU; JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E,. hazelton Ave. , Stockton, Calif. <br /> Teiephone: (209) 466-6781 <br /> �, <br /> APPLICAT�uN FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _E: _j�j� iL/ <br /> THIS PERMIT EXPIRES 1 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 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 Phone <br /> Address City _ <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL f , ' DEEPEN_/ j RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_/-PUMP. REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANY. -� SEWER LINES _ PIT PRIVY <br /> SEWAGE DISk'0 .A, 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 _ _ V a: ave l Pack Depth of Grout Seal <br /> _ Other Rotary Type of Grout C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor -��-750,1-0 _ <br /> Type of Pump U L_-jj.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work gone. <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, <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR P TMENT USE ONLY <br /> r` DATE ' 7 <br /> APPLICATION ACCEPT�D���BY---�� <br /> ADDITIONAL COMMENTS: <br /> &44ajIdROUT INSPEC ' _ON FINAL INSPECTION <br /> INSPECTION BY \ DATE 7,3 INSPECTION B DATE 5� �j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 61,13 <br /> 2 H 1426 7/72 1M <br />