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FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466 -6781 SCANNED <br /> ,-I-37S P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - ,o o w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued > </ <br /> (Complete In Triplicate) <br /> Applicatio 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 le nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' <br /> CENSUS TRACT <br /> Owner's Name f / <br /> Phone <br /> Address <br /> City <br /> Contractor's Name - M1 <br /> !L� <br /> License <br /> t ` ! d Phone —c-33q .. <br /> TYPE OF WORK (Check): NEW WELL /�EEPEN / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ,-SEwER LINES SCJ J—PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _S`— (71-CESSPOOL/SEEPAGE PIT/ OTHER ---�_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT NS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 4--g—omestic/private Drilled Dia. of Well Casinglpq "— <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout eal <br /> Other <br /> �Ratary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor w <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth t <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 /> info tion is true to th est y knowledge and belief. <br /> SIGNED <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FO ARTMENT USE ONLY <br /> PHA�SE�I <br /> APPLICATION ACCEPTED B DATEZ L <br /> ADDITIONAL COMMENTS: /12 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY 6t2DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 W-4/72 1M <br />