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46 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <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. 7 <br /> P (� THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED ; Date Issued <br /> �C' (Complete In Triplicate) <br />!, Application is hereby made to the San Joaquin Local. Health District fora 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 /> 70 <br /> JOB ADDRESS/LOCATION As CENSUS TRACT ' 5­ <br /> Owner's Name VA AL 60 (1 L Phone 1 <br /> # Address '� /� Q City lk 14 d 11/ <br /> Contractor's Name I •/ License # ,(k3a.Phone 0 '2,234,0? <br /> TYPE OF WORK (Check) , NEW WELL "/Ar DEEPEN ./_7 RECONDITION /_7 DESTRUCTION /_7 1 � <br /> PUMP INSTALLATION / J PUMP REPAIR/ J "PUMP REPLACEMENT 177 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD IECESSPOOL/SEEPAGE PIT OTHER <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �. Industrial Cable Tool Dia. of Well Excavation <br /> i Domestic/private. Drilled Dia. of Well Casing 4 �! <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> '-T Other ` Rotary - { :,Type of Grout <br /> Other Othe�rInformation ' <br /> PUMP INSTALLATION: Contractor <br /> Type �of Pump �E �! r' H.P. <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> I hereby agree to Comply with all laws and regulations of the Sari 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 tru ' to the best of my knowledge and belief. _ <br /> r SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> �. FOR DEPARTMENT USE ONLY <br /> .• <br /> PHASE I DATE .: - "" <br /> APPLICATION ACCEPTED_$Y....,. �. <br /> ADDITIONAL t'• t <br /> AL�NSPECTTON <br /> F INSPECTION BY DATE IN ION B DATE - <br /> , ..—CALL. FOR_A_GROUT_INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _-4/_72 1M <br />