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�nSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U5 O1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,_7 <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued F �� <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 CENSUS TRACT <br /> Owner's Name 1 Phone <br /> Address A 4 <br /> City <br /> Contractor's Name �s� � License # Phone <br /> 1 <br /> TYPE OF WORK {Check) : NEW WELL / DEEPEN /7 RECONDITION /'-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other 1/ / _ <br /> ! I <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DIS OSAL RELD CESSPOOL/SEEPAGE PIf05&� OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private F - Drilled Dia. of Well Casing <br /> Domestic/public ! Driven _ _ . .. Gauge of Casing 4- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> [ Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. t <br /> Type of Pump <br /> 1 <br /> i PUMP REPLACEMENT: /_/ State Work Done <br /> w <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter �x Y Approximate Depth <br /> Describe Material and Procedure <br /> + I hereby agree ree 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 DAY <br /> I after completion of my work an 'eriew well; I- will--- furnish the San Joaquin-Local Health Distritt 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. ,may <br /> SIGNED l: A%jv U40 TITLE ��C..� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ix", DATE ll 3 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT !INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />