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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7V_1 <br /> 1601 E. HazeltonAve.;- Stockton, Calif. <br /> Telephone: - .(209) '466-67&16 OGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,4r IS PERMIT EXPIRES.1 YEAR'FROM DAT_E '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 is made -in -compliance with San JoaquiY <br /> County Ordinance No. 1862 •and�the ales and Regu1'ations of the San Joaquin Local health District. <br /> ..! *v`�. . .f' ' ��c .9- CENSUS TRACTS 7 - <br /> JOB ADDRESS/LOCATION Zit v , <br /> IL, <br /> Phony <br /> Owner's';-Name <br /> Address SmfA�✓ - City <br /> V d License #.L7 A-t) Phone .3�I <br /> Contractor's Name <br /> TYPE OF WORK• (Check): NEW WELL'/ / „ DEEPEN "/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTLATION PUMp REPAIR-ie PLTNIP REPLACEMENT /^T <br /> AL <br /> Qther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> CONSTRUCTION SPECIFICATIONS ' <br /> INTENDED USE TYPE OF WELL f1} <br /> Industrial able Tool Dia. of Well Excavation p <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 H,p, •�� <br /> Type of Pump <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP _REPAIR: State Work Done /� .�� 01l '1 <br /> i _ <br /> '~;DESTRU�I`ION OF'WEI:�s"—"We1T"Di:ametet" <br /> 1 Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> he State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> and the <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 trud- to the best of"my knowledge a d belief. <br /> TITLE <br /> (DRAkl PLOT PLAN ON REV�.R <br /> SIGNED SE SIDE) <br /> l FOR DEPARTMENT USE ONLY <br /> k PHASE I DATE _�-/3•_?� <br /> APPLICATION ACCEPTED BY ', <br /> 'ADDITIONAL COMMENTS: i )' PHASE 11 /1'' <br /> INSPECTION <br /> PHASE II GROUT INSPECTIONDATE - - <br /> t 6,11 <br /> INSPECTION BY y DATE INSPECTION BY _/' <br /> CALL FOR A GROUT INSPECTION.,_PRIOR.TO GROUTING AND FINAL INSPECTION. 4/72 IM <br /> EH1426 _ � y <br />