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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. -].3_-Lr <br /> THIS 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 ���� � rr� / v CENSUSTRACT <br /> Owner's Name �4� // . <br /> Phone <br /> Address rS l a a- City <br /> Contractor's Name Ila fGl +�- �? License # ���Phone <br /> TYPE OF WORK (Check) : NEW WELL / ], , DEEPEN /7 .IRECONDITION / .DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT L)ff <br /> Other / / <br /> DISTANCE TO NEAREST: . SEPTIC TANK A eSEWERDINES _ PIT PRIVY <br /> SEWAGE DI'S OS�AL ID C SSPOOL/SEEPAGE PIT <br /> INTENDED USE TYPE OF WELL 696NSTRUCTION S P ECf fttA'TI'ONS' <br /> Industrial C le T Dra. of We 1 Excavation �> <br /> Domestic/private r 11 Di o� We i Ca�sin ,�. <br /> Domestic/public rn aue of Casing4 .. <br /> Irrigation ra a�Pick_- epth of Grout �eaV ° ,a - - <br /> Other RoC rye Type ofrout` �' <br /> 0th Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump ,,rr H.P. <br /> / �'�►^'' <br /> PUMP REPLACEMENT: / State Work Done ? o) <br /> : PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Pro&du ' ' <br /> 4 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 know-le-dae and belief. <br /> SIGNED 1) VERTITLMel E / <br /> PLOT PLAN ON SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE G✓���� <br /> ADDITIONAL COMMENTS: <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 1M. <br />