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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OrWICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 { <br /> (Complete In Triplicate) <br /> Application is herebmade 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 Ord/inaaq,q No. 1862 and the Rules a Re ula ions of the San Joaquin Local Health District. <br /> JOB AADRE 5/LOCATfN [rh- /C ox NN1e S/,O CENS TS TRACT <br /> Owner's Name 12 OAZA I. G` L 1&0 -.I Phone 3 <br /> Address Za D <br /> City f-z5Pz- CA 4;,er— <br /> Contractor's Nath f>5S License # 4 Phone 74j S'/4S-1-- <br /> TYPE OF WORK (Check): NEW WELL 'V DEEPEN / / RECONDITION /-7 DESTRUCTION /- ; <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1156.11 SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 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 91, <br /> Domestic/public Driven Gauge of Casing Az- <br /> - %4 <br /> IrrigationGravel Pack Depth of Grout Seal O <br /> Other Rotary Type of Grout <br /> Other Other Information M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. r <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 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 P PLAN ON REVERSE SIDET <br /> f <br /> FO DEPARTMENT USE ONLY <br /> PHASE I DATE 7'7-- <br /> F APPLICATION ACCEPTED Y <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY - DATE / INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 f 7/72 IM <br />