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;z 1/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,!Z/- 0.2-j :< <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued®Z_f- <br /> 57 �V PJF <br /> /zc ' (Complete in Triplicate) <br /> Application is her byde 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 Regulatior- --1'_-'---'­ Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION S p - - - "� � QSSUS TRACT <br /> R <br /> Owner's Name Phone <br /> Address r City <br /> Contractor's Name License #/ .6p. Phone 7,27• <br /> F <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_� DESTRUCTION /_7 \ <br /> PUMP INSTALLATION' /7/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> 7 <br /> AlISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY A <br /> SEWAGE DISPOSAL FIELD— CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation + , <br /> Domestic/private Drilled Dia, of Well Casing r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel,Pack Depth of Grout Seal , <br /> Other Rotary ti. Type of Grout ' I <br /> Other. Other Information <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump ) i H.P. X21 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> I ,)ES-TRUCTION 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 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 /> information is true to the best/ my knowledge and belief,. <br /> SIGNED TIT E <br /> (DE_V PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 ", '/17 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /,,,g <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />� ' E H 1426 7/72 1M <br />