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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif.' " <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J- (� <br /> • t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <br /> (Complete In Tziplicate)' <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 .�� r�^7��, CENSUS TRACT <br /> Owner's Name r /J I <br /> KelL/�.��+.� Phone <br /> Address 4 „C�-y�.cP City <br /> Contractor's Name License # Phone 3 <br /> TYPE OF 'WORK (Check) : NEW WELL 4V DEEPEN/_/ 'RECONDITION /- DESTRUCTION /-7 - <br /> PUMP INSTALLATION / / PUMP `REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK,/n22 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of"Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing g v m <br /> Domestic/public Driven Gauge of Casing 112- <br /> Irrigation Gravel Pack Depth of Grout Seal 4,01 <br /> Other Rotary Type of Grout C' i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: JW State Work Done <br /> PUMP REPAIR: / / 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 /> SIGNEDTITLE 2m/V <br /> . _ <br /> l (DRAW PLOT PLAN ON REVERSE SIDE) V " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TIT./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION $Y ,� DATE fes: <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />