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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: gLICATION <br /> 1 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-637G✓ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby,made .to the,San Joaquin total 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 Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION O , ! �. i h- C� f?{�/� CENSUS TRACT" <br /> Owner's Name !ZO4 / i " Phone <br /> Address �1 s . . ? rte / d --- --- City <br /> Contractor's Name License # Phone// �f1f <br /> J <br /> f^b <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN 7Z/- RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other Al - �'1� 'fade � Zw�� <br /> ' , <br /> DISTANCE TO NEAREST: SEPTIC ANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLtSEEPAGE -PIT= OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. -of Well Casing Q�� <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 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUC_TION 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, 1 will-fiurnish-the Sari- Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information 's true to the best of my knowledge and belief. <br /> SIGNED I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY R DATE <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 4/72 1M <br />