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�� - --►- `/`^~ !]VI/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i. FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-»6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> . (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 J'oaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,�JOB ADDRESS/LOCATION CENSUS TRACT <br /> ' <br /> ` _ 369 �Z el-3 <br /> Owner s Nam _---J - - _ /1?1 �c rr�_r _._ - --_ _ _ _ -_-_ Phone <br /> Address - �,j �,5�� 721,ry&i ' �C`7. _ City Gn D <br /> San Jrjequin Pump Lo. <br /> Contractor's Name (Division of San Jaagsin Sulphur Co.) License # Phone <br /> 711 N. Sacra7:icrto 5t. <br /> Lodi, L.,a..N_r., 0 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /� RECONDITION X7, DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r PIT -PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial.-%. s— Cable Tool �. Dia. of Well Excavation _ <br /> Domestic/private_ -Drilled ` 'Dia." of`We11 Casing <br /> _Domestic/public Driven Gauge of Casing U` <br /> Irrigation FGravel'—Pack -Depth'of Grout Seal <br /> Other Rotaicy Type of Grout <br /> Other< Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> •PUMP REPLACEMENT: /:; �State Work Done T- <br /> P <br /> i7MP,REPAIR: / / State Work Done <br /> STRUCTION 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 /> 1 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. S}yyp ■y n n I y [( o <br /> onc <br /> i SIGNED TITLE (Division of San Joaquin 54hur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE f" V• 35cramento St. <br /> FOR DEPARTMENT USE ONLY t-wa u'°i1A y,?c-t <br /> � PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / Z6__ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />