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i SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,` Stockton, Calif. <br /> Telephone: (209) '46 6-6781 <br /> r �f,C�C) APPLICATION FOR WELL°CONSTRUCTION OR PUMP PERMIT Permit No. 7,2`67P <br /> THIS -PERMIT EXPIRES l"YEAR FROM DATE ISSUED 'Date' Issued ,/�//-7.1 <br /> (Complete -In Triplicate) <br /> Application isi hereby made'-to' the, Sah 'JoaquiiCLocal` 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'-an& the Rules and Regulations of the San Joaquin Local Health District. <br /> ..•k 'il '. 't•fi n.-. )� i r,. Y' <br /> JOB ADDRESS/LOCATION CENSUS TRACT �Y 7 <br /> Owner's Name 4+ Phone <br /> Address City <br /> Contractor's Name License #,2774jf/ Phone3G,P <br />-TYPE OF-WORK_(Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 ~ DESTRUCTION /_7 <br /> PUMP INSTALLATION /XI PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �;"6 CESSPOOL/SEEPAGE PIT 1p-tl, OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / ;L0 � <br /> Domestic/private Drilled Dia. of Well Casing B9 - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal y p <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br />�P1JMP REPLACEMENT: / / State Work Done <br /> fk <br /> PUMP REPAIR:, J / State Work Done y <br />,DESTRUCTION OF WELL: Well Diameter f 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 c6nsxruction. 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 knowledge and belief. <br /> SIGNED , TITLE <br /> JZ (DRAW PLOT PLAN ON REVERSE SID-ET, <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: /•iz <br /> PHASE II GROUT INSPECTION' PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Z -7 3 INSPECTION BY DATE _3_;L 7-,73 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND`FINAL INSPECTION. <br /> 9 H 1426 7/72 1M <br />