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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V/ 1601 E. Hazelton.Ave ', ?Stockton, Calif• <br /> Teleph6ne: ' Q09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 eo� , <br /> THIS PERMIT"EXPIRES-14YEAR FROM DATE`ISSUEII '; Date Issued," <br /> (C)mplete 'I Triplicate) . <br /> Application is hereby made to ct <br /> ttie :'San edaquThisoaaplicationl Health Diatmade incoimplor a ancewith .Sant to co rictuJoaquin. <br /> and/or install the work herein described. P <br /> County Ordinance No: 1862,,and the- ules and Regulations. of the SariL3o- .%, S3 .0, . & District. <br /> �'3.5"9�l � .i <br /> NSUS. TRACT f 7. <br /> JOB ADDRESS LOCATION -1'w '' <br /> . Phone` F <br /> Owner's, Name <br /> - City. s <br /> Address. 71 <br /> - , <br /> ,!�V License j one <br /> Contractor's Name <br /> _ <br /># TYPE OF WORK (Check): NEW WELL _ DEEPEN /7 RECONDITION-J-7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / ! <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER,LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD iy -CESSPOOL/SEEPAGE PIT' OTHER <br /> ` STYPE O LL r CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE . <br /> ' Cable Tool Dia.. of Well Excavation `I <br /> us trial .,tic/private -,.. Drilled , Dia. of ,Well Casing <br /> p — Domes <br /> Domestic/public ' '�` Driven Gauge of Casing <br /> ' 4. Gravel Pack Depth of Grout Seal <br /> ' Irrigation , <br /> .i iRotary Type of 'Grout _ <br /> Other + <br /> — R Other Other Information <br /> 1 <br /> f- 1 <br /> PIMP INSTALLATION: Contractor H:P. <br /> Type ,of Pump <br /> PUMP REPLACEMENT: / / ' IState Work Done _ <br /> PUMP REPAIR: / ' State Work'DoneN <br /> , I Approximate Depth '_ <br /> ESTRUCTION OF .WELL:. Well .Diameter..._ <br /> k <br /> Describe.Material and Procedure <br /> I 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 /> wil° after completion of my work on a new well, I hemlbefores uttingfurnih theathe owell ninocal use.HeThehaboverict ct a <br /> jWELL DRILLERS REPORT of the well and notify t p <br /> information is ue to the best my knowledge and belief. <br /> TITLE ' <br /> SIGNED (D p T PLAN ON REVERSE SIDE <br /> i� <br /> FOR DEP ARTMENT USE ONLY <br /> PHASE I r DATE 7-1? - �7, <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY et DATE ' 3 INSPECTION BY 1 DATE - <br /> CALL FOR A GROUT INSPECTION:PRIOR.TO GROUTING AND FINAL INSPECTION, 7/72 1M <br /> E E H 1426 <br />