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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466W-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71,/ 38Y <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ` a <br /> JOB ADDRESS/LOCATION / ?C CENSUS TRACT <br /> Owner's Name c3 L_ � I Phone _269 1 <br /> r <br /> Address /Q � �Ee._...._ -� -- City <br /> Contractor' Name ` (�/ 2/L�l,(� - "- -- dLicensePhoned <br /> TYPE OF WORK (Check) : NEW WELL f �DEEPEN /_7 RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INS'TAL`LATION PUMP 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 \� <br /> Industrial - Cable Tool Dia. of Well Excavation ze <br /> Domestic/private- Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing A2 aef <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor � <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR:' " . / / State Work Done <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1310 <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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BYF.. w <br /> ADDITIONAL COMMENTS: DATE� <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT N / <br /> INSPECTION BY DATE INSPECTION BY DATE �� 6 <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />