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UIN <br /> E USE; SAN JOA 4 LOCAL HEALTH DISTRICT <br /> FOR OFFIC <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466_6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pezmit No. 73 �y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " Date Issued f/3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District tqr 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 Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name0 pG�,;;t Phone <br /> Address / -SSC �..✓ City <br /> Contractor's Name <br /> License Phone <br /> .i <br /> TYPE OF WORK (Check): NEW WELLTom/ DEEPEN ./ RECONDITION L-7 JESTRUCTION <br /> PUMP INSTALLATIONS/ PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /% <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /0,72— <br /> Domestic/private <br /> -� =Driiled- Di-a, of We'11 Casing ;. <br /> _ Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel pack Depth of Grout Seal ; <br /> Other Rotary -Type, of. Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP REPAIR° / / State. Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <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 re Matin well construction. <br /> g g Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wiil ,f,urnish 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -J(, <br /> ADDITIONAL COMMENTS: <br /> P SE II GROUT INSPECTION'-' Y- - - — PHASE-I I .FINAL INSPECTION <br /> INSPECTION BY lQp,, DATE Z INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND- FINAL INSPECTION, <br /> E H 1426 <br /> 7/72 1M <br />