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vo SAKI JOAQUIN LOCAL HEALTH DISTRICT <br /> FCkk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .,Co r✓ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z-1 7Q CENSUS TRACT <br /> Owner's Name Phone Y7 7`" <br /> Address zS'Qa _ City S7dQr ro <br /> Contractor's Name P . License # 7(46Z_ Phone y6.t--4rr <br /> TYPE OF WORK (Check): NEW WELL / . DEEPEN /% RECONDITION /0 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 Q„a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal UV If <br /> _X Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor [ lC ���� ur C�CD <br /> Type of Pump / l H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION 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 /> 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 i _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> . _._. _._.._.,_,_,._.••FOR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY Ay DATE 0/// <br /> ADDITIONAL COMMENTS: 77 <br /> PHASE II GROUT INSPECTION PHAS IIi FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />