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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 FOk-WELLrCONSTRUCTION OR PU:W PERMIT Permit No. <br /> r <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 :Wade in compliance with San Joaquin <br /> County Ordinance •No.• 1862"and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> • ` rya - . - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Yf Phone <br /> Address �f.�Y IG aI- _. � n <br /> .�'. c�..�.�.�. . ..., city <br /> Contractor's Name , , License ` a 3 Phoned aS <br /> TYPE OF WORK (Check) : NEW-WELL /7 DEEP-ET % / -RECONDITION /� DESTRUCTION/� <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 iE <br /> w. . Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES � PIT�PRIVY <br /> SEWAGE DISPOSAL-FIELD _CESSPOOLJ•SEEPAGE"PIT- ._ OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1 <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-4- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ `� s`I` <br /> State Work_Done <br /> PUMP REPAIR: State Work Done <br /> .! 41,,,_V ' <br /> ESTRUCTION OF WELL: Well Diameter"-. _� ' Approximate Depth <br /> Describe Material and-Procedure <br /> i <br /> I hereby agree io 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. ' <br /> SIGNED )-n--PAA-J bw TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDE) 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �"�` DATE + <br /> ADDITIONAL COMMENTS: Ca <br /> PHASE II GROUT INSPECTION PHASE IIi/FINAL INSPECTION <br /> INSPECCTION BY DATE INSPECTION BY DATE- <br /> CALL FOR A GROUT INSPECTION„PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />