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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 /> AMD <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.ZL� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED:' Date Issued2L7) <br /> �l"' (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 7 1 `� �5 � CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address . 11 City SC ALV- <br /> Contractor's NameSbAlf License #(.e?. . ' APhone <br />= <br /> TYPE=OF-WORK- -(Check): -NEW WELL /�/ DEEPEN j /�:-RECONDiTrON-/-z- DE'STRUCTI-ON-/� <br /> AL - " <br /> PUMP INSTALLATION /1� PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /-7 <br /> JG ; <br /> iI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ]; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE, l <br /> E TYPE OF WELL ,; CONSTRUCTION SPECIFICATIONS _ <br /> Industrial Cable Tool - <br /> Dia. -of Well Excavation i1 <br /> Domestic/private Drilled Dia. of Well Casing``! J <br /> Domestic/public Driven Gauge of Casing LI -� <br /> Irrigation Gravel Pack Depth of Grout Seal! <br /> Other Rotary Type of Grout <br /> Other Other Information I� { <br /> PUMP INSTALLATION:' Contractor <br /> Type of Pump =4-r- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> 01STRUCTION-OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure if <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 weil in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE)-- <br /> FOR <br /> IDE V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY ,,J� DATE 1PI-1 �— <br /> ADDITIONAL COMMENTS: IfI <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 4gW= DATE INSPECTION BY DATE -Z - '� , <br /> CALL FOR A GROUT,INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.;; <br /> E H 1426 7/72 1M <br />