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!J4,r�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT c, <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. c� 4Z� l <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _73- 1G z W <br /> 73- /6Si' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4- 7 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 N EE. ED CENSUS TRACT <br /> Owner's Name L. L Phone - 114'7 <br /> Address .23 zl,?3 ?tE4.1&&cX City <br /> Contractor's Name License # && Phone �- <br /> TYPE OF WORK (Check) : NEW WELL /,--?'DEEPEN /_7 RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION� /i/" PUMP REPAIR / / PUMP REPLACEMENT /� <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 j,---Cable Tool Dia. of Well Excavation �- <br /> mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary .....: Type of Grout <br /> Other Other Information <br /> t � <br /> PUMP INSTALLATION., Contractor <br /> Type' of..Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP REPAIR: / / State -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 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 of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY - -PHASE I <br /> APPLICATION ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �, �- DATE ZI-2 - _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 7/72 . 1M <br />