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SAN JOAQUIN LOCAL HEALTH DISTRICT" JFOR OFFICE- 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: , (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. 77- <br /> THIS PERMIT EXPIRES l YEAR' FROM DATE ISSUED , Date Issued 6, ? 3 ,� <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / � � / 2- D/Z CENSUS TRACT <br /> Owner's Name WA"/f'' Phone � 2 <br /> Address City G 2 <br /> / r <br /> Contractor's Name wzzf-'` �� /_l/( /( License �� -Phone � Y <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN �� <br /> PUMP .INSTALLATION / / PUMP REPAIR/ J PUMP-REPLACEMENT /? <br /> Other' / <br /> DISTANCE TO NEAREST: SEPTIC; TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE - WELL CONSTRUCTION SPECIFICATIONS <br /> E industrial '. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f: Gravel Pack Depth of Grout Seal L. <br /> Other 3- Rotary Type of Grout C ru __- 1711 a <br /> Other Other Information' '� ® <br /> PUMPINSTALLATION: Contractor <br /> r Type of Pump H:P. <br /> PUMP REPLACEMENT: / / 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 tocomply with all lams and regulations of the San Joaquin Local Health District <br /> and the State of California pertai.ning •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 /> M information is true to the best of my knowledge and belief. <br /> SIGNED A TITLE //Z 41- <br /> G' (DRAW PLOT PLAN ON REVERSE SID ) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C, DATE ��,✓ <br /> ADDITIONAL COMMENTS: <br /> PHASEGROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,121DATE Z INSPECTION BY5 DATE - 3 <br /> CALL FOR A GROUT INSP CTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M `'^ <br />