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,/-),y v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �'OF..OFF ICZ USE- .160 . E. Hazelton Ave. , Stockton, Calif. <br /> --- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Tz3__ D/ 61 <br /> .IL <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )2 ` 7`73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> work herein described. <br /> and/or install the - This application is made in compliance with San Joaquin <br /> County Ordinance._Na.� 1862 and the Rules and Regulations ofeth.San Joaquin Local ilealth strict. <br /> *j.TOB�ADli SS/I�OGAT CENSUS TRACT <br /> Phone <br /> owner's Name <br /> City ' <br /> Address � oD, <br /> A License <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other ./ / <br /> DISTANCE T4 NEAREST: SEPTIC TANK SEWER LI1�ES PIT PRIVY <br /> SEWAGE DISPUSAL FIELD CES POOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA IONS <br /> Industrial Cable Tool Dia. of Well Excavation ! 4 <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/p Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor <br /> l Type of Pump H.P. <br /> fI- PUMP REPLACEMENT: / / State Work Done <br /> j PUMP '2EPAIR: ' / / . State Work Done <br /> DP��TRUCTIAN OF WELL: Well Diameter <br /> Approximate Depth <br /> Describ aterial and Pro'edure <br /> if .I hereby agree to 4&;y$)w-ith <br /> ws anregu ations o the San Joaquin Local He th District <br /> AYS <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN D <br /> after completion of my work on a new well, I will furnish the Ban Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well a d notify them before putting the well in use. The above <br /> information is rue to the bes a3ny knowledge and belief. <br /> TITLE <br /> SIGNED (DRAW PLO AN ON REVERSE SID <br /> + FOR PART <br /> USE ONLY <br /> G PHASE I DATE ---41 ACGEPTED .BY <br /> ADDITIONAL CO14II1fENTS: PHASE II/FINAL- INSPECTION <br /> PRASE GROUT INSPECTION INSPECTION 13Y DATE ;-, <br /> INSPECTION BY <br /> DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/73TMM <br />