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IW3w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> G APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�,7- ,/0 4�' <br /> THIS PERMIT EXPIRES '1 'YEAR FROM DATE ISSUED Date issued /,,.__2o_,.2z <br /> (Complete In Triplicate) <br /> Application is 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 Joaquiv <br /> County Ordinance No.18 d e Rules and Regulations of the San Joaquin Local: Health District. <br /> /LOCATIONi CENSUS TRACT J <br /> Owner's Name Ii(1Phone <br /> 4 <br /> Address W , =p uL rt ' City <br /> r <br /> Contractor's Name License ��67K&Phone <br /> '- TYPE-OF WORK (Check): !ANEW WELL f2;7' DEEPEN / / RECONDITION %� DESTRUCTION /� T _ <br /> "PUMP INSTALLATION/� PUMP REPAIR / / 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 l--Cable Tool Dia. of Well Excavation / 2- <br /> ` dr Domestic/private. t-, 'Drilled Dia, of Well Casing t• <br /> Domestic/public F. Driven Gauge of Casing - <br /> 4.- Irrigation_ Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout [aieYy <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> PUMP _REPLACEMENT: 4 / State Work Done �• - �. <br /> PUMP REPAIR: „/ / State Work Done <br /> DEST-R_ UCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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. f <br /> ' SIGNED TITLE <br /> S <br /> 7 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE d p <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> t INSPECTION BY DATE /I_ INSPECTION BY f/,,, ,.` DATE//-y-7- 72--' <br /> _ <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />