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SAN JOAQUIN`-LOCAU HEALTH DISTRICT <br /> FOR vFf*ft USE: `J 1601 E. Hazelton Ave., Stockton, Calif. <br /> Cr Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J3- 257 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' Date Issued <br /> i�r_ Ef �tfi J<4 /ujR (Complete In Triplicate) <br /> Ap'plicati6n'18`hereby'made�to the San Joaquin Local Health District for 4 permit to' construct <br /> and/or install the work herein described. This application is made in complianoe-wlth San Joaquin` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. k <br /> JOB ADDRESS/LOCATION <br /> f.w �( 7 /j(//�{�, 4N'" CENSUS TRACT LoS-o7o-YD <br /> Owner's Name to Phone <br /> ;7J4 3 � <br /> Address <br /> Contractor's Name License N 1,20'72 Phone f�3d'-9�J0 <br /> TYPE OF WORK (Check): NEW WELL / IT DEEPEN /% RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /% PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% „4 <br /> ) i <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 Rf 2ju <br /> Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> � h <br /> IJ <br /> E PUMP INSTALLATION: Contractor <br /> ` Type of Pump H.P. <br /> j PUMP REPLACEMENT: / / State Work Done <br /> } PUMP REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter —Approximate Depth —--- <br /> Describe Material and Procedure <br /> I herebyagree 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 knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> HASE <br /> FOR DEPARTMENT USE ONLY <br /> PI <br /> APPLICATION ACCEPTAV DATE <br /> I'S'PECTION <br /> ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS • I I F NAL INSPECTION <br /> BY DATE INSPECTION BY DATE - 7� <br /> CALL FOR A GROUT INSPECTION-.PRIOR..TO .GROUTING AND FINAL INSPECTION. - <br /> I E H 1426 7/72 1M1`RS <br />