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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: <br /> Telephone : (209) 466--6781 <br /> APPL CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��(_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuee/E Z <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 Rues and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT -- <br /> (;�,, Phone <br /> Owner's Name "1 lam. <br /> Address City <br /> - <br /> Contractor's Name License #d_SS111 Phone <br /> TYPE OF WORK (Check): NEW WELL / I DEEPEN_ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other [_7 T <br /> DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES 0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> �. Domestic/public Driven Gauge of Casing ^ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information O <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: I>a State Work Done �_ -�.1 ,...��„M J„ <br /> PUMP REPAIR: / / State Work Done <br /> i � <br /> ESTRUCTION 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 /> I 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 /> 1 ��FhRDEGARTMVT <br /> TITLE <br /> SIGNED VERSE SIDE <br /> SE ONLY <br /> PHASE I _ DATE <br /> APPLICATION ACCEPTED BY <br /> JADDITIONAL COMMENTS: PSE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> bINSPECTION BY DATE INSPECTION BY _ <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPEC N. <br /> 7/72 1M <br /> r E H 1426 <br />