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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E0r."O1PICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /I!a-7s' <br /> (Complete In Triplicate) <br /> Application is hereby made!to the San Joaquin Local Health District for a permit toaconstruct <br /> and/or install the work herein described. - This application is made in compliance with San Joaqui <br /> County Ordinance -No. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address Q City ' fir/ <br /> Contractor's Name <br /> - License # f kV37 .Phone �y <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ j RECONDITION/_/ DESTRUCTION /-7 <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /-7AL <br /> other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial F Cable Tool Dia. of Well Excavation <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 /> i Other Other Information ' ' <br /> I + <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / /. State Work Done <br /> 'UMP `tEPAIR: /-7 State Work Bone edw o <br /> # ,PFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I . <br /> Describe Material and Procedure <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 <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 � ��- [' 1z TITLE <br /> s <br /> (DRAW^PLOT PLAN ON REVERSE SIDE)^ <br /> 3 FOR DEPARTMENT USE ONLY <br /> p P11ASE I <br /> s APPLICATION ACCEPTED .BY /" lit/ DATE .11—Irl - 73 <br /> ADDITIONALCOMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY� DATE INSPECTION BY ?k DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> V u IA-)e 51731M <br />