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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haze-l.tori`AV'e.: - Stockta:.-z, Calif. <br /> Telephohe.- (203) .466--6781 <br /> - <br /> APPLICATION FOR WELL CONSTRUCTION:OR PUMP PERMIT Permit No. 7 2 '_ 5 D <br /> THIS PERMIT.'EXPIRES 1 YEAR--FROM DATE 'ISSUED <br /> 9 <br /> C Date Issued g 7 z <br /> (Complete Ih Triplicate) <br /> Application is;herebyimade to -the San.-Joaquin Local Health District for a- permit to construct y <br /> and/or in-stall 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/L:CA&TIO I"/( <br /> P CENSUS TRACT <br /> Owner-'.s Name <br /> Phona, � ,�,� <br /> Address . <br /> :Z� <br /> City <br /> Contractor's Name 4 <br /> icense # <br /> TYPE OF WORK (Check) : NEW WELT, DEEPEN / / RECONDITIO_/? DESTRUCTION <br /> PUMP INST LT,ATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LIES <br /> SEWAGE DISPOSAL FIELD PIT PRIVX <br /> CES POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATION <br /> Cable Tool Dia. of Well Excavation 41 <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> -Domestic/public Driven Gauge of Casing .41 <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 <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> �UMP REPAIR: State Work Done <br /> ESTRUCTION OF WELL: °Well Diameter <br /> Describe Material and Procedure Approximate;Depth.-_.. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 d notify them before putting the well in use. The above <br /> information is rue to the bes my:knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW P PLAN ON REVERSE SIDE) <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICAT ON ACCEPTED BY i <br /> ADDITIONAL COMMENTS.' DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �„ DATE t/ . LINSPECTION BY _ <br /> DATE72, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />