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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.117 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'Date Issued /p.;z .. 3 <br /> in Triplicate) <br /> Application is hereby made to the San (Joaquin eLocal 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 oval Hea tDistrict. <br /> JOB ADDRESS/LOCATION 4 yzec, ) <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 7 4E A. <br /> City <br /> Contractor's Name <br /> License # l.zf Phone z*17z.-- ' p <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Othe / 7 <br /> DISTANCE TO NEAREST: SEPICAN K <br /> SEWER INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> COo <br /> Industrial <br /> CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled Dia. of Well Casing V` <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: # <br /> Contractor <br /> Type of Pump e k <br /> � H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Dome <br /> Ali <br /> 2� <br /> ESTRUCTION OF WELL: Well `D'ia�meter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Focal 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 rue to the best of my knowledge and belief. 'II <br /> SIGNEDf <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID-EE4 <br /> PHASE "I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .001 , <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE Ii FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE �/p-/�-73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. <br /> E H 1426 7/72 1 <br />