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r � <br /> AAN JOAQUIN LOCAL IiEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Ha.zeltori 'Ave. ° Stockton, Calif. <br /> Telephone: '(209) 466--6781 <br /> AffPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS.-PERMIT .00/7)- <br /> 'EXPIRES I'.YEAR.:`FROM°DATE ISSUED Date Issued <br /> (Complete .In Triplicate) <br />` Application is .hereby made- to-�the .Sal n, 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 :Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . o aw i �O&.axp ¢ CENSUS TRACT <br /> Owner's Name, ��. k :._. Phone ' 7.x-7 ' <br /> Address / G o .S 6 4.1rpt City <br /> Contractor's Name License # lt3 1,�PPhone -W 7l <br /> TYPE. OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR /�(/ PUMP REPLACEMENT -7 <br /> AL <br /> Other <br /> \ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> T <br /> Industrial Cable Tool Dia. of Well Excavation T <br /> Domestic/private Drilled Dia, of Well Casing 41 <br /> Domestic/public Driven Gauge of Casing, j <br /> Irrigation �-°�^ - -Gravel' Pack-"'"--`- -' `Depth of Grout Seal - <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> - 1 <br /> � I <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> C.'r <br /> i <br /> PUMP REPLACEMENT: / / - State Work Done <br /> PUMP REPAIR: / State Work Done Q_ -� <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 /> k 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 /> SIGNED ITLE <br /> W PLO PLAN ON RFKERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE -LIZ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3-72. <br /> CALL FOR A GROUT INSPECTION,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />