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L <br /> c, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466--6781 <br /> V <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date- Issued // G J,2 <br /> (Complete In Triplicate) `" <br /> j Application- i6 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 Joaquir <br /> f County Ordinance No., 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !� CENSUS TRACT <br /> Owner's Name , , g / / <br /> GQ-�. Phone <br /> Address <br /> city - <br /> Contractor's Name __ License. #1� ,96 <br /> Phone 9z <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /? DESTRUCTION /rj <br /> PUMP INSTALLATION / J PUMP REPAIR /T PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ---7—SEWER- LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> p r <br /> INTENDED USE TYPE-OF-WELL- """T ` —"' 'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private' Drilled Dia. of Well Casing 'Q. <br /> Domestic/public Driven Gauge of Casing All <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> r PUMP INSTALLATIONo Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: w /�/ State Work -DoneA P_ <br /> DESTRUCTION OF WELL: - Well Diameter <br /> Approximate Depth <br /> Describe -Material and Procedure <br /> C <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State -o€ 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 /> t 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 /> SIGNED11a.; X711 TITLE <br /> (DRAW P OT PLAN ON REVERSE SIDE <br /> r <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ,. <br /> APPLICATION ACCEPTED BY DATE �— <br /> F ADDITIONAL COMMENTS. <br /> PRASE Il GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> E INSPECTION BY DATE T INSPECTION BY DATE= <br /> CALT. FOR A GROUT INSPECTION PRIOR TO GROUTING.ANDFINAL INSPECTION. <br /> I <br /> E H 1426 7/72 1M <br /> i <br />