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' SAN JOAQUIN LOCAL HEALTH T)ISTRICT <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. 72 ZLM60 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 11111917-12J <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 with San Joaquin <br /> County ordinance No. 1862 and the Rules an Regulations of the San Joaquin Local Health District. <br /> ,708 ADDRESS/LOCATION 4 CENSUS TRACT <br /> i <br /> Owner's Name s Phone V37- a <br /> I <br /> Address City <br /> Contractor's Name 0 License # 118S,' Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/'7 RECONDITION /-7 DESTRUCTION /7 Y T <br /> PUMP INSTYLATION PUAi'P REPAIR / / PUMP 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 G <br /> — Domestic/private - - Drilled Dia. of Well Casing v <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 n <br /> PUMP INSTALLATION; Contractor <br /> Type of PumpV H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Dane <br /> PUMP REPAIR: _ / / State Work Done <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 /> 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DE NJ, S ONLY <br /> PHASE I <br /> APPLICATION ACCEP DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASEF.II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - - 7-1- INSPECTION BY el. DATE —, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M L� <br />