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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> XPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-_ '70 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2_17­77_ <br /> t6_-70 S . Sccr�tr�-t Ffar-cam [>� -.. (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 a dd' the4�Rules and egu51_attioo s of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone + <br /> 47 <br /> Address _ f(5--7f1 �S' ��c�,.7 �� ix/ � City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK .(Check) : NEW WELL/L/ DEEPEN /_/ RECONDITION /_7 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/SEEPAGE PIT OTHER J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � } <br /> Industrial Cable Tool Dia. of Well Excavation 15 <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 7' Rotary Type of Grout <br /> Other Other Information <br /> i <br /> 's <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ s <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 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1441FINAL INSPECTION <br /> INSPECTION BY DATE r INSPECTION BY DATE 0-,--?—_D2-- <br /> CALL <br /> -,--?—_D2CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />