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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ?6_/300 <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION V / Al CENSUS TRACT <br /> Owner's Name r ( e srpn- Phone ^ 22,QC <br /> Address City 4��O_o/ - <br /> Contractor's Name /} ( P" 44 License if 316 3?kPhone 366 SV7 <br /> TYPE OF WORK. (Check): NEW WELL / / DEEPEN /_% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / 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 <br /> Domestic/private Drilled Dia. of Well 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. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /ivstate Work Done IL 36 /-//a / .@ /.0 Ar2 DIf <br /> ,DESTRUCTION OF WELL: Well Diameter 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 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 knowledge and belief. San ,Joaquin Pump Co. <br />' SIGNED �r (Division of Sao Joaquin Sulphur CO-) <br /> TITLE -711-N. Sacramento St. <br /> (DRAW PLOT PLAN ON REVERSE SIDE Ladi.,California 95x4a <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINa INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />