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F. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Ug. Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - Z-jla1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 7T/ ; <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 / +2. CENSUS TRACT <br /> Owner's Name Phone <br /> I <br /> Address City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/-7 ~RECONDITION /—]` DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/$EEPAGE 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/public Driven Gauge of Casings - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other -ZSR— Rotary Type of Grout <br /> Other Other Information <br /> E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 FIFTEEI DAYS <br /> after completion of ark on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RE of the well and notify them before putting the well in use. The above <br /> information true f m knowledge and belief. <br /> NED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '�-1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE T N PHASE III FINAL INSPECTION. <br /> INSPECTION BY �10,_ DATE INSPECTION BY I DATE O 46 NL <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. <br /> E H 1426 4/72 1M , <br />