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- 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> / PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> HIS 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 ����� ,� /e� CENSUS TRACT <br /> .Owner's Name /'LGPCL= �.f'f Phone !3I— J,7-7-3 . <br /> Address City: _ <br /> Contractor's Name \`—" f� .�- License # �Phone <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN RECONDITION RECONDITION /-7 DESTRUCTION /- <br /> t PUMP INSTALLATION —PUMP REPAIR/)ff PUMP REPLACEMENT /- <br /> Other ,/ / ►-x <br /> DISTANCE TO NEAREST: SEPTIC TANK LIN PIT PRIVY <br /> SEWAGE DISPOSAL FIE YGE,,�IT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation c� <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 <br /> PUMP INSTALLATION: Contractor TT <br /> Type of Pump i H.P. p P <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> -� <br /> PUMP REPAIR: / / State Work Done 44 4?44 ta- <br /> ,DESTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and. Procedure �---� <br /> t 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 /> informatio is true to the best of my knowledge an belief. <br /> f <br /> j SIGNED - ITLE <br /> (DOW PLOT PLAN ON REV , SE SIDE) <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .®; � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> J�W <br /> E H 1426 4/72 1M <br />