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'll j <br /> 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. Z-/ 0 `f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q-/ yL <br /> (Complete In Triplicate) <br /> Application is h reby 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/tft-ATrON G� CENSUS TRACT <br /> Owner's Name . :.071-1 <br /> 91. Phone <br /> Address City <br /> Contractor's Name &gar _Y14� �P License' <br /> Phone <br /> TYPE OF WORK (Check) : NEw WELL /��DEEP N %-1 RECONDITION /; � DESTRUCTION /7 <br /> TV <br /> PUMP-INSTALLATIOIV % �PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' 6 L— Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> !-- Irrigation's Gravel Pack Depth of Grout Seal ® ! . <br /> Other Rotary Type of Grout <br /> Il, Other i Other Information _.._. <br /> PUMP INSTALLATIONa Contractor D YWQ,4 e <br /> Type. of Pump g,` H.P. / r <br /> PUMP REPLACEMENT: /M / State Work Done Y <br /> PUMP REPAIR: /,I:/ State Work Done ! <br /> �EST_R_UCTION OF WELL: Well Diameter Approximate Depth =. <br /> Describe Material and Procedure <br /> IN <br /> I hereby agree to comply�jwith 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 "Pu' tting the well in use. The above <br /> information is true to the best of my knowledge and belief': <br /> SIGNETITLE' - <br /> �I. (DRAW_PLOT PLAN ON REVERSE SIDE <br /> `PHASE I - - - <br /> FO DEPARTMENT USE ONLY <br /> lAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROU `I P ` TIO - PHASE`III/FINAL'INSPECTION <br /> INSPECTION BY "DATE -7 INSPECTION BY DATE 7-- <br /> h <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. , <br /> E H 1426 7/72 iM 1 <br />