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r <br /> V SAN JOA UIN LOCAL HEALTH DISTRICT <br /> STRICT <br /> f0r.',Ol1ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73-Sy? kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oz install the work herein described. ' This application is made in compliance with Sart Joaquin <br /> County- Ordinance No. 1462 d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l� �� CENSUS TRACT .0-5:Y- V?0—f3 <br /> Owner's Name Phone-3( "• F a <br /> Address �j ,�,,� <br /> City <br /> Contractor's Name �-�' <br /> ^_ License Ile Phone 7�+�j <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION 1-7AL <br /> PUMP INSTLATION J J PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `y <br /> Industrial /a'r`e Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing d' <br /> _ _LLr4t ion Gravel Pack Depth of Grout Seal w , <br /> Other Rotary Type of Grout *' f <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.- <br /> PUMP REPLACEMENT: <br /> / J State Work Dane <br /> PUMP UPAIR: / / State Work Done <br /> ,DF�TRUCTION OF WELL: Well Diameter Approximate Depth ; <br /> Describe Material and Procedure i <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 iaell and notify them before putting the well in use. The above ' <br /> information is true to the best my knowledge and belief. <br /> SIGNED 6 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY _ DATE l 73 <br /> /Q: <br /> ADDITIONAL COMMENTS: " "— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION 'PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 [� /71zu <br />