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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.7 3 - 1 '5q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application A hereby 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/LOCATION - axl? C,(foic �a,_� � : G CENSUS TRACT <br /> Owner's Name �e�-�'- /j�-�-•� �c� F �-�/ Ph <br /> .6 X,-3 -- <br /> Address -rrd1J CityG-r' <br /> Contractor's Name ✓ , Li ense # Phone Lll <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP PAIR / / PUMP REPLACEMENT /7 <br /> Other Ll <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 7 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _ / / State-Work Done _ <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 /> 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 a:,Z_4 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR E ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTDATE 7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHWIIIPT#AL IN=CT22N <br /> INSPECTION BY DATE INSPECTI <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. (43 <br /> E H 1426 7/72 1M --� <br />