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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> [ FPR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. <br /> - P <br /> Q <br /> THIS PERMIT .EXPIRES I YEAR FROM DATE ISSUED <br /> Date Issued _0*-7 2 <br /> Application is hereby made to the :San (Complete In Triplicate)Joaquin Local Health 'District for a permit to construct <br /> and/or install the work. herein described. This <br /> application <br /> Joauin <br /> County Ordinance No. 1862 and the .Rules and Regulationsofthe SaneJoaquinpLocal eHealthwithSan District. <br /> JOB ADDRESS/LOCATION : # <br /> CENSUS TRACT' <br /> I ,.^= <br /> Owner's Name �T'C �, <br /> Phone _ <br /> Address <br /> City <br /> Contractor's Name <br /> i <br /> License #/B ?YL Phone -76 7L <br /> TYPE OF WORK (Check) : NEW WELL / / 'DEEPEN /�~/ RECONDITION DESTRUCTION /_' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other '/ / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS o�ry <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Domestic Dia• of Well Casing <br /> /public � <br /> Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout V) <br /> Other Other Information c <br /> 1 <br /> PUMP INSTALLATION: Contractor - { <br /> Type of Pump <br /> H'P. <br /> PUMP / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL. Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 kno dge an belief. <br /> SIGNED (� /�} „ %�_ TITLE <br /> (D OT AN ON ERSE SIDE ?.,0.-� i <br /> PHASE I OR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY e"? <br /> AbD1�' <br /> ITIONAL COMMENTS: I DATE, <br /> INSPECTION BYPHASE II GROUT INSPECTION PHASE LIVFINAL INSPECTION <br /> DATE INSPECTION BY <br /> ,, DATE 0 � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM QO - <br />