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_ SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> FOR OFFICEIUSE: 16(AE. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> NAP CATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. 72- 6 q <br /> !s <br /> Iis PERMIT EX?IRES 1 YEAR FROM DATE ISSUED . Date Issued <br /> t: (Complete In Triplicate) ` r <br /> .Application is hereby made bNthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> n <br /> County Ordinance No. 1862 and-,the Rules and Regulations of the San Joaquin Local Health District. j <br /> JOB ADDRESS/LOCATION _ Z CENSUS TRACT ' E <br /> ,. -— Phone d!a <br /> f� <br /> 6- <br /> owner's Name-_ 9 <br /> Address 00 � f� �_ City <br /> a <br /> a <br /> Contractor's Name "; , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIRm/ I PUMP REPLACEMENT Je- <br /> Other <br /> DISTANCE TO NEAREST: SEPTICATANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t � . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack -Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. t <br /> 4 k*e REPLACEMENT: State Work Done 1 " -.I.- <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION OF WELL Well Diameter 4 _ �, 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 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 the1well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> 01( <br /> + TITLE <br /> SIGNED <br /> (DRAW PLO PLAN ON REVERSE SIDE) <br /> FO DEPARTME USE ONLY <br /> E! PHASE I <br /> APPLICATION ACCEPTED BY - -� DATE - 7 <br /> ADDITIONAL COMMENTS: , <br /> PHASFII GROUT ,INSPECTION P SEIII/FINAL INSPECTION <br /> INSPECTION BY� DATE _ --- INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION.` <br /> 4/72 1M <br /> E H 1426 _ <br /> s; LY <br />