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V ` SAN JOAQUIN LOCAL HEALTH DISTRICT - - FOR OFFICE USE: 1601 E. Hazelton Ave.,, Stockton, Calif. Telephone: (209) 466-6781 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3 �S THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 9-�3 (Complete In Triplicate) k_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is-made incompliance with San Joaquin County Ordinance No. 1-862 and the Rules and Regulations of the San Joaquin Local Health District. j � / /f/Ii.Sri c� �cc JOB ADDRESS/LOCATION:,:. _rLriz 7 I CENSUS TRACT _. . ' Owner's Name Phone ' 4�4 j_ Address 4 City m,, Contractor's Name License 'Phone 4 _0 ,4 TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 - PUMP T - PUMP INSTALLATION X PUMP REPAIR/ / PUMP REPLACEMENT /7 Other —� � �1fBrf ff DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' Industrial Cable Tool Dia. of Well ExcavationE. Domestic/private Drilled Dia. of Well Casing Domestic/public Driven Gauge of Casing Irrigation Gravel Pack Depth of Grout Seal Other Rotary Type of Grout Other Other Information A 5 � PUMP' INSTALLATION: Contractor Type of Pump H.P. f. PUMP REPLACEMENT: / / State Work Done E PUMP REPAIR: /% State Work Done ,pESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District. and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS after completion of my work on a new well, I will furnish the San Joaquin Local Health District. a WELL DRILLERS REPO"f the well and notify them before putting the well in use. The above information is t e t6 the be of my nowledge and belief. r SIGNED TITL (DRAW PLOT PLAN ON REVERSE SID i OR DEPARTMENT USE ONLY PHASE Ip ; APPLICATION ACCEPTED BY DATE ADDITIONAL COMMENTS: PHASE ,II GROUT INSPECTION PHAS II FINAL INSPECTION INSPECTION BY—�� DATE . INSPECTION BYDAT ` �tl E CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL;INSPECTI E H 1426 4/72 1M :- ;