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*1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave".. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS -PERMIT EXPIRES -1 YEAR°FROM DATE ISSUED Date Issued <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 /> Y County Ordinance No. '1862 ani& the 'Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L�Z�9,�ENSUS TRACT <br /> Owner's Nam f ° 7�:s <br /> "° Phone <br /> U <br /> Address J,� ity <br /> Contractor's Name Licenser �`3 2- �'� Phone? <br /> TYPE OF WORK (Check):..:. W WELL _. _ DEEPEN /�__ RECONDITION I_ _--DESTRUCTION_._ - <br /> t.r-.. — r - _ �� <br /> PUMP INSTALLATION 4/ / PUMP REPAIR I / 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 L---Mble Tool Dia. of Well Excavation <br /> �, - timestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven 'Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Others Other Information`s <br /> PUMP INSTALLATION: Contractor Ai <br /> r Type of Pump -5TI H.P. <br /> PUMP REPLACEMENT: / / ' State-Work <br /> State-Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 4 ,pE9TRUCTIONY6F WELL: We'l-I Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � t . <br /> I. he.reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> t 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-(T) '`TITLED ` <br /> a (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I ... # 1� <br /> , APPLICATION ACCEPTED BY DATE 7 Z.Z,17,j' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY - DATE /G-] INSPECTION BY <br /> DATE 1,6 <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. 7- <br /> E H 1426 7/72 ll � <br /> h <br />