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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.��4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -p is Zr„t -w-;• t'T , _ (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 .2 CENSUS TRACT <br /> Owner's Name A44 - Phone <br /> Address `o City : <br /> Contractor's Name License # aQ72 Phone g�-- 7 t� <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN /_/ RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I�T <br /> Other L-1 -d-4400Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS w <br /> Industrial - Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing _ /O .PJr— /_LA <br />' Irrigation Gravel Pack Depth of Grout Seal ! <br /> Other N. Rotary Type of Grout <br /> V Other Other Information <br /> der <br /> PUMP INSTALLATION: Contractor : ( - <br /> Type of Pump, _ .. -_ - --_ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done r s <br /> ,DESTRUCTION OF WELL: Well Diameter E Approximate Depth <br /> Describe Material and Procedure 11 <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 /> ' information is true to the best of my knowledgeand belief. <br /> SIGNED i TITLE <br /> MV (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I � d <br /> APPLICATION ACCEPTED BY GF/e DATE �� z <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHA§ I FIN INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE 4 - <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. j 0 <br /> E H 1426 `" 7/72 1M <br />