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SAN JOAQUIN LOCAL HEALTH DISTRICTf k ��f �O� <br /> FOR OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. ( e4, <br /> , 2. 9 -2-co-0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate, -- / j``-�- <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 � , A_P , / CENSUS TRACT <br /> l ( ctir.ti. <br /> Owner's Name Phone <br /> Address p u ,�' . a if <br /> City <br /> Contractor's Name License # fl?�J1� Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 • <br /> PUMP INSTALLATION —/ / .PUMP REPAIR <br /> Other PUMP REPLACEMENT /� <br /> /% <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 3 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: X/ State Work Done <br /> .pESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /_1 8 �. <br /> } e .a� �?a ��tt,� TITLE <br /> (D PLOT PLAN ON REVERSE SIDE- <br /> j �� .L �_ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; DATE <br /> PHASE II GR T INSPECTION <br /> INSPECTION BPHASE III INAL INSPECT ON <br /> Y DATE INSPECTION BDATE 73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />