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, �6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a- /,-7--`/.14/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -&_s-76 <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. 186 and the Rul_e� and Regulations of the San -Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION %y .�P � � 00 S I70 22 <br /> ENSUS TRACT <br /> Owner's Name , <br /> � Phone 300 <br /> Address 7� E7 CitY , <br /> Contractor's Name cense #11 y' lql Phone.�� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION t?// .UMP REPAIR / / PUMP REPLACEMENT /-7 <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 O <br /> Industrial �_L,::f£able Tool Dia. of Well Excavation m <br /> 1--' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal 10 <br /> Other Rotary Type of Grout _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Ptim L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 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. <br /> SIGNED 4 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT -USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE 3/2- <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GRQUT INSPECTION PHASE III VINAL INSPECTION <br /> INSPECTION BINSPECTION BY DATE I Ig-�� <br /> CALL FOR A GROUT IlrSVECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />