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U.Lr . <br /> N 0 ALT1Ir I� RICT � <br /> FOR OFFICE USE: 1601 E. azelton Ave. , Stockton, Calif. <br /> Telephone (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1-OZ� <br /> THIS PERMIT EXPIRES 2 YEAR FROM DATE ISSUED Date Issued/,e.. <br /> (Complete In Triplicate) <br /> Application is` ereby made to the San Joaquin Local Health District for a permitto construct <br /> q P <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 2-0 ,�'� CENSUS TRACT y,S' <br /> Owner's Name4DOa ..Y Phone <br /> Address .5, - s&+. Cityuwl4r 1 <br /> 47 <br /> Contractor's Name License# Phone 4 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN -,7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR J / PUMP REPLACEMENT " <br /> Other <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 ca <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 "5 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /State Work Done s <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 Rppalth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. " The above <br /> information i rue to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE �.- <br /> r (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: .c <br /> PHASE II GROUT INSPECTION PHASE I;XjFTAAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />