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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. «1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . -�a 72 <br /> i (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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> �istrict. <br /> i <br /> C <br /> TOB ADDRESS/LOCATION 1QQ Q O <br /> kC <br /> Owner's Name . <br /> ^t'Q 1. G ! Ny Phone X66 6 3 <br /> .Z-S 34 4 .IIIA i . Sr <br /> Address - <br /> Contractor's Name �� � License #c;gWaPhone Tvrr-63 7` <br /> TYPE°OF WORK (Check) : NEW WELLDEEPEN / RECONDITION /_7 DESTRUCT1ON _/_7' . <br /> PUMP INSTt- LATION I I PUMP REPAIR I I PUMP REPLACEMENT I�T <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE_PIT �Qf OTHER <br /> � f '� O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ONS d" <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> dr <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal. �_Sn <br /> Other Rotary Type of Grout <br /> Other Other Information L696 %A S-410-Z 30 <br /> IV L6N-6-1 i-t UEAK TQ - A_ <br /> PUMP INSTALLATION: Contractor G 1N <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t PUMP REPAIR- / / + State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> I <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 knowle nd elief. <br /> SIGNED (AA4 TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1„r, r � Y � DATE <br /> APPLICATION ACCEPTED BY "�/ Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ 4�2 DATE ./� - __ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> `7E H 1426 7/72 1M <br />