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SAN JOAQUIN LOCAL HEALTH DISTRICT t �` <br />' FOR OFFICE USE: <br /> k1111111601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : <br /> APPLICATION FOR `WELL CONSTRUCTION 6ORIPUMP PERMIT <br /> Permit No. Zz <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ? <br /> � {Complete In Triplicate) <br /> Application is hereby bade to 'the' San Joaquin Local Health District for a permit to construct <br /> and/or install the worst herein d. 'jyhiS ��a ation made �n compliance with San Joaquin <br /> County Ordinance Na. 1 2 an s B <br /> aquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone t <br /> Address f <br /> City <br /> Contractor's Name <br /> 4 LicenZAP Z 3 Phone <br /> J u <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /. / RECONDITION /_7 DESTRUCTION = <br /> /� •�� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK __ CE <br /> SEWER LINES <br /> SEWAGE DISPOSAL FIELD — PIT PRIVY <br /> SSPOOL/SEEPAGE PIT <br /> OTHER � <br /> INTENDED USE TYPE OF WELL <br /> ndustrial CONSTRUCTION SPECIFICATIONS <br /> D <br /> le Tool Dia.-,of Well Exc <br /> Domestic/private Drilled avation 7 77— <br /> Domestic/public Driven Dia.. o€ Well Casing <br /> Irrigation Gauge of Casing <br />`— ' Gravel Pack Depth of Grout ,Seal <br /> Other Rotary Type of Grout <br /> Other Other Informati n <br /> PUMP INSTALLATION: Contracto <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work `Done <br /> PUMP-REPAIR <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local health District <br /> tnd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> tfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.nformation is true to the best of my knowledge and belief. <br /> IGNED <br /> rTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED �BY"INSPECTION <br /> DDITIONAL COMMENTS: DATEPHASE II <br /> NSPECTION BY INSPECTION BYHASE III FINAL INSPECTIO <br /> DATE DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING ?r <br /> E H 1426 AND FINAL INSPECTION. <br /> ; <br /> 7/72 ICO <br />