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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .7 <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 Joaquin <br /> County Ordinance No. 6 he Rules and Regulations of the San Joaquin Local Health District. <br /> Sc -z— <br /> JOB AD SS/LOCATION �f,/ f.�"j/� 6�VzrA? CENSUS TRACT ! AJ tZ S`�: <br /> Owner's Name <br /> � rr . <br /> - � .� ' Phonq(v� <br /> Address L, . d-7� /li s� s�-� C f9,C City ; <br /> Contractor's Name "7 / CC C' <br /> �� �y4�a.1 — License 7 Phone �TYPE OF WORK (Check) : NEW WELL 'j/ DEEPEN /_/ RECONP,ITI-Off/_ m DESTRUCTION /'j <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK w' 4; SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ."FIELD f ' CESSPOOL/SEEPAGE <br /> " PIT •°- , � <br /> A2 THER <br /> i� <br /> " ' elf '4 a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Z <br /> Industrial .3 � Cable Tool „ Dia. of Well Excavation <br /> Domestic/private Drilled "-r. '- V% Dia, of Well Casing / <br /> Domestic/public{ Driven '. Gauge of Casing p <br /> Irrigation*' Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type .of..Grout ... � - <br /> Other Other Information' °r <br /> PUMP INSTALLATION.- Contractor �,•�. i C� �1GEsdvl <br /> Type of Pump r �� 1/ F ... - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P-�W REPAIRWork";Done « --- ."�'.� .� � •»�..W- .� <br /> ESTRUCTION 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 DistrictLL <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 { .r TITLE Td <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B G DATE r" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ✓ DATE -/ '71V <br /> CALL FOR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />