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FOR OFFICSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 7�-�7S1J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate I <br /> ssued <br /> (Complete <br /> -asrov_ <br /> Application is hereby made to the SanJoaquin LocalrHealth District fora ermit to <br /> and/or install the work herein described. This application is made in compliance with nSan uJaa uin <br /> County Ordinance No. 1862 and the Rules an egulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION UWOO <br /> Q <br /> CENSUS TRACT <br /> Owner's Name "01 ft <br /> -- Phone <br /> Address _ 1 <br /> City _ <br /> Contractor's Name <br /> ��- License W Phone _0 <br /> TYPE OF WORK (Check): NEW WELL /' , DEEPEN /? RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR / --PUMP IMEPLACEMEN� <br /> Other %/ — T /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK "� <br /> EWER LIDS.` FIT PRIVY <br /> SEWAGE DISPOSAL FIELDSiL <br /> / SSPOOLJSEEPAGE PITS OTHER <br /> INTENDED USE TYPE OF WELL ° f <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation (� <br /> �bomestic/private Arilled Dia. of' Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing -- <br /> Gravel Pack Depth of Grout S <br />_-- Other Mary Type of Grout _� <br /> Other Other Information <br /> a2pt:,S <br /> PUMP INSTALLATION: _ <br /> Contractor <br /> Type of-Pum a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP <br /> _ . Y1 <br /> 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 District <br /> and the State of California pertaining to orregulating well construction. Within FIFTEEN DAYS <br /> after completion of my work. on a new we11,- I will furnish -the -San Joaquin Local Health District a <br />&LL DRILLERS REPORT of the well and-notity them before putting the well in use. The above <br /> Cn€o tion is true to the b knowledge and belief. <br /> SIGNED - - <br /> ` w TITLE <br /> y PL T PLAN ON REVERSE SIDE _ <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> . PHASE I.3 R N x•ar r► r -,a ,. rd,-- , <br /> NSPECTION.BY - r i ' ( PHA$E ILII/FINAL INSPECTION <br /> T INSPECTION BY ,��/( DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 IM <br />