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A 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. 7 -dd0 V <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ L- <br /> (Complete In Triplicate) 7�Sra d <br /> I <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 7 .C1�i? > IIL �CN .�?l _ Phone5�5`- <br /> Address Z City i <br /> Contractor's Name A1A11A1 —. License # 3y 2.Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION f7/ DESTRUCTION /_7 <br /> PUMP INSTALLATION. / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK c° SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL 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 6 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout C-1 <br /> ` Other Other Information ;. <br /> N <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> r r V <br /> PUMP REPLACEMENTS / / State Work Done 1 <br /> PUMP REPAIR: / / State Work Done <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 Ys rue to the be,t of my knowledge and belief. <br /> SIGNED r TITLE L/1J t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br />. APPLICATION ACCEPTED BY r y DATE / <br />: ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE I I !NAL INSPECTION <br /> INSPECTION BY T DATE - - INSPECTION BY ( DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _51.4 7/72 1M <br />