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SAN JOAQUIN LOCAL HEALTH 'DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. �.S= I <br /> FOR OFFICE USE: Telephone: (209) 466-6781 <br /> V4, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ;7, S <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUEd <br /> DS� 0Date Issue --L---- <br /> F yK £ �� •; (Complete In Triplicate) /! truct <br /> a permit Application is Hereby made to�the San Joaquin Locallication Health District <br /> inrco pliancetwithnSan Joaquin► <br /> and/or, install the work herein described. This app <br /> County0`rdinancr . No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's. Name <br /> _5f�� city uC <br /> .Address _ <br /> Licens�'fl' � Phone <br /> Contractor's Name <br /> t <br /> / / RECONDITION DESTRUCTION <br /> WORK NEW WELL DEEPEN <br /> TYPE OF ( REPAIR / PUMP REPLACEMENT IT . <br /> PUMP INSTALLATION IGI� <br /> Other <br /> SEWER LIKES PIT PRIVY OTHER <br /> - DISTANCE TO NEAREST: SEPTIC TANK. CE55POOC/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD <br /> ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Tool Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> mestic/private Drilled <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 /> � + A <br /> PUMP INSTALLATION: Contract H,P, <br /> Type I of Pump <br /> j <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> 4 <br /> StateW <br /> ork Done <br /> PUMP—REPAIR:—/ <br /> Approximate DepthWell <br /> �ESTItIIGTION OF WELD Describe Material and Procedure <br /> lth <br /> rict <br /> I hereby agree to comply with all laws and regulations °well construction.LOWithinaFIFTEENtDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION - 7S-7 <br /> �� INSPECTION BY DATE <br /> INSPECTION BY _ DATE — <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 - - <br />