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r 'y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOR.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 l <br /> YEAR FROM DATE ISSUED <br /> Date Issued ZLI <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 Loc 1 Health District. <br /> �LOCATIr 1 <br /> JOB j <br /> <d�GC�[.� r <br /> 10 CENSUS T12ACT <br /> Owner's Name <br /> - Phone <br /> AddressCitx�� /�� �- <br /> retractor s Name / License ° < <br /> hone -- <br /> TYPE OF WORK (Check): NEW WELL /V/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTLATION / / PUMP REPAIR <br /> Other / / PUMP REPLACEMENT /- <br /> �" <br /> i V <br /> DISTANCE TO NEAREST: SEPTIC TANK LSEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ivk SOL/SEEPAGE PIT -f-OTHER <br /> e INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation Z r <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/ <br /> Irrigation <br /> Driven Gauge of Casing -_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotor � <br /> y Type of Grout <br /> Other Other Information <br /> ki <br /> PUMP INSTALLATION: ContractorY <br /> ' <br /> Type of Pump �c <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> _ / / State Work-Done <br /> RESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth ` <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 /> Enformation is true to thebestof my knowledge and belief. <br /> SIGNED TITLE �jf�l <br /> (DRAW PLOT PLAN ON REVERSE SIDE e E <br /> FOR DFwPARTMENT USE ONLY <br />'BASE I <br /> 1PPLICATION ACCEPTED BY DATE <br /> WDITIONAL COMMENTS: _ - _ <br /> PHASE-11-GROUT-INSPE'CTIO —. <br />[NSPECTION BY _ - "PHAS III FTIVAL INSPECTIO " <br /> DATE 2 3 . 1NSPECTION BY DATE D 73 <br /> CALL FOR A GRO T INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br /> E H 1426 <br /> 7/72 ZN[ <br />