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r SAN JOAQUIN LOCAL HEALTH DISTRICT ��� .. <br /> FOR OFr10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1g <br /> • Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL�CONSTRUCTION "OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES--I-XEAR FROM DATE ISSUED Date Issued 1 3 <br /> e -,� : . (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.; 1862 and-:the Rules and Regulations .of the San Joaquin Local Health District. <br /> ' 8DtESS/1.00ATXON IA)! ` <br /> S� C�ENSUS�TRACT . 3�/ r <br /> Owner's.Name - F Phone ' ; <br /> Address f City <br /> Contractor's Name 1'CJ =License'#a Phone - <br /> _j <br />`"TYPE"OF WORK (Check{): NEW WELL R DEEPEN `•/V RECONDITION DESTRUCTION;L <br /> PUMP INSTMATION / / PUMP, REPAIR / / PUMP REPLACEMENT <br /> -Othen.-.ja.j� <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER"'LI PIT PRIVY r <br /> SEWAGE DIS PO AL°FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ' TYPE OgL CONSTRUCTION SPECIFi IONS , <br /> Industrial W. Cable Tool + Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ;Gauge of Casing <br /> rrigation Gravel Pack ' Depth of Grout'Seal <br /> Other +.�' Rotary Type of Grout ' <br /> k Other Other Information C <br /> -' �� �l" <br /> n <br /> PUMP INSTALLATION;: or""-W ' <br /> Type of Pump H.P. <br /> s } 4� € <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP REPAIR: <br /> . / / .-�$Cate Work�Done_,� <br /> ,AESTRUCTION OF WELL: Well Diameters Approximate Depth .,-, <br /> Describe Materidl and Procedure <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 <br /> WELL DRILLERS REPORT of the well nd notify them before putting the well in use. The above (� <br /> information is ue .to t e bes my nowledge arid>belief. <br /> TITLE <br /> SIGNED - . <br /> (DRAW P PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> I <br /> PHASE I' <br /> APPLICATION'ACCEPTED BY ~~ L4 DATE ' cS 3 <br /> ADDITIONAL:COMMENTS: <br /> PHASE. II GROUT--INSPECTION. . ' PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ..s 5-1-7j <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H '1+26 v 4/72 1M <br />