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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: '(204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '2- Z1,LJ+ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issued' 11,0- 3. 7a <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 aiid the Rules and Regulations of the San Joaquin Local Health DistriA. <br /> JOB ADDRESS/LOCATION 9h liirtDf -- CENSUS TRACT <br /> Owne 's NameSNI C, Phone Z <br /> Addr Gss � 4/� L,��ya/I N City Ali fOl ��1 <br /> Contractor's Name G G/! lLj/1 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN / RECONDITION / J DESTRUCTION /_7 <br /> PUMP INSTALLATION ;/_/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /% o/ 4 if/' see -Z. C' �4�/_ L,'�2 <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 V <br /> ff Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private . Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge. of Casing <br /> a Irrigation Gravel Pack Depth of Grout Seal F <br /> Other Rotary, Type of Grout <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION✓ Contractor <br /> Typelof Pump H.P. <br /> PUMP REPLACEMENT: / / jState Work Done <br /> PUMP REPAIR: / / aState Work Done <br /> (,DESTRUCTION OF WELL: Well,Diameter Approximate Depth <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+pe.rtai.ning to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my worklon 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 truetothe. best of my knowledge and belief. <br /> SIGNED ---- --- -- - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR .DEPARTMENT USE ONLY <br /> PHASE I A 7 <br /> APPLICATION ACCEPTED BY DATE( 94"{�j <br /> : ADDITIONAL COMMENTS: <br /> PHASE II GROUT' INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY . DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 7/72 1M <br />