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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. 73-2�7a <br /> THIS PERMIT EXPIRES 1 ,YEAR FROM DATE ISSUED Date Issued-5 �/ 3 <br /> (Complete In Triplicate) -5'O r07 <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 - , Q CENSUS TRACT <br /> Owner's Name Phone <br /> Address ya -- 7 City <br /> Contractor's Namer, fA-- y—' License 2V,,2 ,j!(Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /-7 RECONDITION /_� DESTRUCTION /? O <br /> PUMP INSTEUTION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 p <br /> Other LJ 412W — --- - [,� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �Y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �+ <br /> Industrial j Cable Tool Dia. of Well Excavation VA <br /> Domestic/private Drilled Dia. of Well Casing <br /> —7y1 0 . <br /> Domestic/public Driven Gauge of Casng <br /> Irrigation Gravel Pack Depth of Grout Seal. U <br /> Oiher Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> Approximate' ESTRUCTION OF WELL: Well Diameter A pp Depth <br /> Describe: Material and Procedure <br /> i 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 fQI - <br /> (DRAW PLOT PLAN ON REVERSE SIDE UM <br /> FOR DEP T USE ONLY <br /> PHASE I \1 ACCEPTE DATE �2- - - <br /> ADDITIONAL COMMENTS: All <br /> RMIL" ECON �DATQ <br /> INSPECTION INSP <br /> INSPECTION BYDATE <br /> INSP BY <br /> g` { <br /> F CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />