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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave.- Stockton, Calif. <br /> Telephond.—'(209) 466--6781 <br /> ;;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z- too P <br /> THIS PERMIT�EXP:IRES.•1'YEAR'FROM DATE' ISSUED Date Issued `�-IL--7 <br /> 7/ <br /> ' . j - (Complete `Ing Triplicate) <br /> Applicatio ,:is; erebyzmade:.to :the:, Sari;Joaquin- Local Health Di-strict for a permit �to construct <br /> and/or install the work herein described. This, application' is. made- incompliance .with San Joaquin <br /> County,Ordinance No.'�1862.land�-the•..,Rule s`*and" Regulations 'of `the San'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f1 ly t✓ i N: A// '�}L�j�vENSUS TRACT" <br /> Owner';S)Name`A ; <br /> Phone t <br /> Address f �L f�LtfiS a� <br /> �.� City <br /> Contractor's Name a License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIRPUMP 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 /> Domestic/publicDriven 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 ' <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: State Work Done JW 0 „ <br /> .pESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Jaws 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 /> r � <br /> SIGNED ) <br /> �-�' v TITLE <br /> (DRAW P PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY D TE INSPECTION BY f DATE �� { <br /> r <br /> CALL FOR A GROUT_ INSPECTION._PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H-1426 4/72 1M <br />