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M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) .466-6781 i <br /> LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j 7o-Z2 <br /> P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LT I Z,-�-: , <br /> (Complete In Triplicate) A <br /> Application is hereb made to the San Joaquin Local Health District for a permit to construct ' <br /> I <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.i <br /> V <br /> JOB ADDRESS/LOCATION 9 9 �adr . ,!_ P,,. e� CENSUS TRACT „ <br /> Owner r& Name Phone <br /> Address -„ .7 - .� Zz�� r, { � City ? <br /> Contractor's Name License # Phone <br /> TYPE OF WORK {Check) : NEW WELL /_/ DEEPEN / / RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR k/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE " TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ij <br /> i <br /> Industrial Cable-:Tool Dia. -of Well Excavation <br />'j Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public Driven Gauge of Casing -n <br /> Irrigation Gravel Pack Depth of Grout Seal Wl <br /> Other Rotary Type of Grout G <br /> Other Other Information i <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. '�!I <br /> PUMP REPLACEMENT: % / State Work Done T 'I <br /> PUMP REPAIR: / State Work Done N `i <br /> i� ' y <br /> 4 -DESTRUCTION OF WELL: Well Diameter Approximate Depth jr <br /> Describe Material and Procedure <br /> A � <br /> ,5 a <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 j <br /> information is true to the best of my knowledge and belief. <br /> SIGNED u TITLE jl <br /> {DRAW 7LOT P'LAN ON REVERSE SID <br /> .I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE II FIN NSPECT10 <br /> r iNSPECTIflN BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO-GROUTING AND FINAL INSPE ION. j <br /> E H 1426 11 7/72 1M <br /> :i <br />