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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. 7.2--65TP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IL)-11-72- <br /> (Complete <br /> dy/-7z(Complete In Triplicate) <br /> Application is hereby made 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 Ordinance No. 1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. e- (&CENSUS TRACT 01 4--old}-�c(/ <br /> G - v <br /> Owner's Name j + ' Phone <br /> Address Cityt9 z�' <br /> f x <br /> Contractor's Name . License # LZIU Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/. PUMP REPAIR )2�/ PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ^� <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 —� <br /> Domestic/public Driven Gauge of Casing s <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout -L <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done J <br /> Cw 'J <br /> .DESTRUCTION OF WELL: Well Diameter L�f�_ _ Approximate Depths <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 /> informatio •is rue to t best of my knowledge and belief. <br /> SIGNED %' TITLE <br /> %i 1 , ;� F!t/•� �< (DRAW PLOT PLAN ON REVERSE SIDE \ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ii FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a-12-77.- <br /> CALL <br /> -- -7yCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />