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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF CE USE; i"_ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. 3_� # <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEAISSUED E <br /> -� Date ;.Issued <br /> i (ComOlete `In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health' District for 'a perinitTto construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1852 and! Rules and Regulations o£ ihe ``San Joaquin Local Health District. } <br /> JOB ADDRESS/LQC-Z76 ��AT . <br /> CENSUS TRACT " <br /> Owner's Namem - <br /> 'Phone. SO <br /> Address <br /> City <br /> Contractor's Name <br /> License #.2 ZC <br /> 2o /p Phone <br /> TYPE OF WORK (Check): NEW WELL�/% DEEPEN%�� RECONDITION /.? DESTRUCTION.' /77', <br /> PUMP INSTALLATION /. / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD Wil" _t CESSPOOL/SEEPAGE PIT f OTHER <br /> JNTENDED USE TYPE OF WELL , i <br /> Industrial CONSTRUCTION .SPECIFICATIONS J ' <br /> Cable Tool Dia, of Well Excavation O <br /> Domestic/private I Drilled Dia. of Well Casing` <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout- Seal <br /> Other [ Ratary ` Type of Grout,, <br /> { 1 Other "r Other Information , <br /> i ---------------- <br /> PUMP INSTALLATION: ' Contractor <br /> Type of,-Pump <br /> iy. <br /> H.P. <br /> PUMP REPLACEMENT: /d State Work Done 044& l�� s <br /> PUMP=REPAIR:-= - / /-=State Work--Done -- - - �-- <br /> ESTRUC_TION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I hereby agree to comply, with .ZTlaws.. and-regulations-of the-San Joaquin -Local He_A th-District Ii <br /> and the 5tate -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 the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. <br /> SIGNED. <br /> TITLE, <br /> ? A (DRAW PLOT PLAN ON REVERSE SIDE ', � , <br />'RASE I 7 : : , i FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY:'", �A4, ►� �" ti <br /> LDDITIONAL`COMMENTS• : DATE <br /> N "PHASE II-GR IN ECTION_ f II NAL INSPECT N <br /> CNSPECTION BY �, i �DATE--- INS DATE 3 <br /> %- i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 <br /> 7/72 1M �3 <br />