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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 /> _,,✓ PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z 3 <br /> THIS PERMIT EXPIRES '.1'. YEAR FROM DATE ISSUED ' Date Issued f- /­7 is <br /> rr� ; (Complete In Triplicate) <br /> Application is .he eby 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 Jaj <br /> County Ordinance No. 1852 and'.the Rules and Regulations of the- San Joaquin Local Health Distriicci. <br /> nk CENSUS TRACT <br /> JOB ADDRESS/LOCATION v� Z 21 <br /> P r{ <br /> Owner's Name Phone' - CZ e <br /> Address_ - City <br /> Contractor's Name License .# &.23 7 Phone, �- 1 7 <br /> TYPE OF..WORK (-Check) : NEW WELL '/ DEEPEN ( T <br /> RECONDITION /_7 DESTRUCTION /7 PUMP INSTALLATION / / PUMP REPAIR ''-PUMP REPLACEMENT /_T <br /> Other <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED -USE STYPE OF WELL "CONSTRUCTION 'SPECIFICATIONS E <br /> In Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> I` Domestic/public Driven Gauge of Casing _ <br /> Irrigation ' Gravel Pack DephoffGraut Seal t <br /> Other Rotary Type <br /> Other . Other Information <br /> i NJ <br /> PUMP INSTALLATION: Contractor � + Z <br /> Type of Pump H.P. 1 <br /> 9 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done _ <br /> _ 1 <br /> 1. ,PESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> h all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply with g <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 /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY tzz <br /> DATE —2— <br /> ADDITIONAL COMMENTS: <br /> PHASE III GROUV INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />