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. ( SAN JOAQUIN LOCAL UEALTU 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. '3- 7/ k) <br /> THIS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED ; Date Issued -2 <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 /> JOB ADDRESS/LOCATION ?w �'L, L�. JJ CENSUS TRACT ' S � <br /> Owr►er s Name 'u �.ff Phone 36 fpad _ <br /> Address r fLCity <br /> Contractor's Name �� P/l/ � License # / Phone ' - 8- <br /> r e <br /> TYPE OF WORK _(Check)_:_ NEW-WELL <br /> .eRECONDITION_w � DESTRUCTION-/ . <br /> PUMP INSTALLATION PUMP REPAIR/ PUMP REPLACEMENT 17 <br /> -- <br /> Other <br /> DISTANCE TO NEAREST,: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 00 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> __,.,::fDomes tic/private Drilled Dia. of Well Casing <br /> I Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type _of Grout <br /> Other Other Information T <br /> 1 <br /> PUMP INSTALLATION: Contractor f " <br /> Type of Pump i _w: H.P. e . <br /> PUMP REPLACEMENT: ' <br /> / / State'WorkDone' <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: YWell' Diameter Approximate—Depth- <br /> Describe Material and Procedure <br /> I.hereby agree_ to comply.with, all laws--and„regulations ,of, tie ..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 J� - -- - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY - DATE z;�” 1173 <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 4/72 IM <br /> r <br />