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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <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 � � CENSUS TRACT <br /> Owner's Name Phone '— <br /> Address Q , City _ <br /> Contractor's Name N op <br /> 11111,21111411, R License # y honeG276�'6 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION /1 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 <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 /> __K _ Irrigation Gravel Pack Depth of Grout Seal 1 <br /> Other Rotary . Type of Grout .� <br /> Other Other Information <br /> Ir I <br /> PUMP INSTALLATION: Contractor .-�> y� G . <br /> Type of Pump ,� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done e <br /> J?ESTRU_C_TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material -and Procedure <br /> I hereby agree to comply with all laws and re'gulati'ons 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 kn edg and-belief. <br /> SIGNER V `� TLE <br /> (DRA P 0 PLAN ON RE RSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIAM PHASE I I ZINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - �- DATE yY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />