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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (204) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No./;, -- F7V <br /> THIS PERMIT EXPIRES-1 YEAR FROM DATE' ISSUED Date Issued ,p, �z <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 Joaquin <br /> County Ordinance No. ]. 62 nd the Rules and Regulations of the Sa ZJ q in Local Health District. <br /> /LOCATION .S` Q V' F CENSUS TRACT <br /> / !E 7 <br /> Owner's Name 1(AL1-W.` .Zt4 l Phone . <br /> Addressr--D f2 . . I�GI City <br /> Contractor's Name A0 OV 44A <br /> 4C�r License ? Phone <br /> TYPE-OF WORK (Check): NEW WELL 'X" DEEPEN /7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION#/' PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK C) SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL-FIELD - - -EESSPOOL/SEEPAGE--PIT - —'"OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS n , <br /> Industrial A -Cable Tool Dia. of Well Excavation 'tom <br /> s/ Domestic/private A— Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ��J <br /> Other Rotary Type of Grouter <br /> Other ._� Other Information <br /> PUMP INST"AiLLATIONaContractor S� S <br /> Type of Pump / H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> -PEST <br /> TRUC ION OF WELL: Well Diameter " Approximate Depth <br /> Describe Material and Procedure � t <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 ofsthe 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 <br /> -- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)T." <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE Id ao <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. <br /> E H 1426 7/72 1M <br />