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SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> . ,41FY USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-6781 -7 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7k✓ <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued /0-13--73 <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 /> xJOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name C� Phone <br />` Address LIQ. <br /> City . <br /> Contractor's Name.- <br /> License #AfiPhone''��� <br /> TYPE OF WORK (Check) : NEW WELL DEEP / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMA INSTALLATION �J PLTMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LIN S PIT PRIVY <br /> SEWAGE DISPOSALFLD 2'SU CESSPOOL/SEEPAGE PIT OTHER J <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 <br /> public Driven Gauge of Gasing _ <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR.: / / State. Work Done t <br /> ,DF'RTRUCTION 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 on a new well, I will furnish the San Joaquin Local Health District a E <br /> WELL DRILLERS REPO .of .th well and notify them before putting the well in use. The above <br /> information 's a to th my kn edge and belief. <br /> SIGNED., j TITLE C <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ATE ' �� 3 <br /> ADDITIONAL COMMENTS: 77 <br /> P E II GROUT INSPECTION PHAS INSPEe/7 CTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> ­CALL.FOR-AaGROUT..INS.PECTION..PRIOR»TO_GROUTING AND_FINAL ,INS <br /> E H 1426 -�-- <br /> __ C /7Z,.. <br />