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SANT JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ICT <br /> ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7Z_- � LEL <br /> i <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is, hereby -madd Issued <br /> Date <br /> 8-a�-7Z <br /> (Complete In Triplicate) !Z7- zGo-- a2_ <br /> 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 District. <br /> JOB ' DRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name.SG* <br /> t Phone <br /> r Address <br /> City <br /> Contractor's Name <br /> License # LJJ2) phone = tea <br /> F � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_l / RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 5EWER"-LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER � <br /> Y INTENDED USE' TYPE OF WELL <br /> InduCONSTRUCTION SPECIFICATIONS <br /> strial <br /> Domestic/private Cable Toni Dia. of Well Excavation_ _-- Domestic/public Drilled Dia. of Well Casing „ <br /> Driven Gauge of Casing <br /> _ Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> k - OtherOther Information <br /> PUMP INSTALLATION: �+ <br /> =: Contractor <br /> i Type of Pump. <br /> H.P. <br /> PUMP REPLACEMENT: ` / / State Work Done <br /> PUMP REPAIR: <br /> /KI State Work Done P ' <br /> r � <br /> ESTRUCTION OF WELL: Well Diameter , <br /> � xE. <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with,-a-11-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 owledge belief. <br /> SIGNED <br /> LE <br /> ( PLOT PLAN ON RE RSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 7 Z <br /> i <br /> CALL FORA GROUT I,NSPECTION;PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ., E H 1426 <br /> = <br /> 7/72 IM <br />