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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: s <br /> U Telephone; (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., , <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to `thSan JquThisoapplicationDistrict made inrco pliancea permittwithnSanuJoaquin <br /> and/or install the.work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> A09V TRACT <br /> .TOB ADDRESS/LOCATION ,- <br /> Phone <br /> Owner's Name Cit /7IJ <br /> '- Address <br /> License # 14 X 73 Phone <br /> r Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN <br /> PUMP INSTALLATION /__PUMP REPAIRI/N7/ P[TMPESTRUCTION REPLACEMENT�I�T <br /> f <br /> Other <br /> -------------------------- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI CESSPObL/SEEPAGE PIT OTHER <br /> ,. SEWAGE DISPOSAL FIELD <br /> INTENDED USE ' TYPE OF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled -Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of. Grout <br /> Other _ Other', Information <br /> PUMP INSTALLATION: Contractor c@ H.P. l <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4�_Pt3MP REPAIR: ^� _ �/�/=S'tate-•Work=Done=�'.�•-`^-�-�..�F . - � -- - -- <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> 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 + <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 /> �? ° TITLE -t �•2 ,.sar✓ <br /> SIGNED Y-..e w.,,� .�. _ .s.e�� � e •� - <br /> f (DRAW PLOT PL2�N ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P I /FINAL INSPECTI N <br /> C PHASE G OUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> I CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ION. 7/72 1M <br /> E H 1426 - - <br />