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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 /> APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k <br /> /O- _7 <br /> (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin Isocal Health District for a permit to construct: <br /> and/or install the work herein described. This application is made in compliance with San Joaq in: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ili 7o4i IV , c0 <br /> CENSUS TRACT _ <br /> I Owner's Name G u rc. 492 APhone <br /> Addressv 7,6-c e M AG <br /> City <br /> Contractor's Name 4-t-, 3 <br /> License # Phone G y <br /> f h _/7—RECONI)-ITIO —/'DESTRUCTION <br />' TYPE •OFYWORK• (Check.); --NEW WELL_/�`}DEEPEN' ---��---�--� <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other — <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 14 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O' <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary_ Y Type of Grout re <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:— ." <br /> /_7 State Work bone <br /> PUMP REPAIR: + <br /> . �Xf State Work Done <br />.DESTRUCTION OF WELL' Well iameter <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 /> SIGNEDTITLE p c <br /> C-�-� - <br /> RAW PL PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY APPLICATION �J���CATION ACCEPTED BY '7 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 " <br /> 7/72 lM <br />