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SAN JOAQUIN LOCAL HEALTH DISTRICT �a <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. �� <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED Date Issued kj 2�& -9- <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 <br /> ndd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Jr, � CENSUS TRACT <br /> Owners Name Phone $ - <br /> Address City S <br /> Contractor's Name D1 , - 4� © ; : .. License # (J Phone g v07 <br /> c .ZU/ �.., <br /> ��.. . . w... - - <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /% RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /PUMP REPAIR /—/ PUMP REPLACEMENT /-T <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 LZ i2e S-2 y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i-1 State Work Done <br /> PUMP REPAIR:- / / State-Work' Done <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 Distriet. 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 Ira TITLE ._ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br />'ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAJE I INAL INSPECTION <br /> INSPECTION BY DATE -' INSPECTION B-Y ( Ll DATE -20- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M _Dot <br />