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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 ES <br /> V/ E. Hazelton �ve. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT -Permit No. a-ZZI-7 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j2- <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 CENSUS TRACT <br /> Owner's Name -- �4 L.-9 Z Phone <br /> Addressl� City go-A .,.,,,... <br /> Contractor's Name S (t (! License # j / Phone, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <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 \ <br /> Domestic/private Drilled Dia, of Well Casing <br /> Ddmestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S. (� <br /> Type of Pump oF- - - H.P. <br /> PUMP REPLACEMENT: State Work Done. <br /> 6� :LA"'q �8ri1°� <br /> PUMP REPAIR: / / State Work Done <br /> i <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY1. -) .:H DATE �.. 74 ::2 <br /> ADDITIONAL COMMENTS: � 1 <br /> PHASE. II GROUT INSPECTION PHASE IUaINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL ''"FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - <br /> E H 1426 7/72 1M <br />