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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16.01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> i <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED bate Issued <br /> jdbo <br /> (Complete In Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <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 /> J7/Ql <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT. <br /> Owner'e.: Name ' <br /> Phone - d� <br /> Address <br /> City. <br /> Contractor's Name <br /> License �If Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECON - -- -- � - <br /> _ / DITION /_� DESTRUCTION /-7 b <br /> PUMP INSTALLATION /7 / PUMP REPAIR —/—/ PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT4 <br /> OTHER <br /> INTENDED USE TYPE OF WELLf <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> T Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout w <br />-----� i Other Other Information <br /> PUMP INSTALLATION: i <br /> Contractor <br /> Type of Pump J-4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'REPAIR <br /> __.-- / / State""Work Dane <br /> ESTRUCTION OF WELL: Well Diameter - <br /> Describe Material and Procedure Approximate Depth <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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. ,rp' <br /> i I GNED �j <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEP TMENT USE ONLY <br /> 1PPLICATION ACCEP DATE <br />►DDITIONAL Co <br /> Af <br /> E UT INSPECTION PHASE II FINAL INSPECTION <br />;NSPECT ON BY DATE INSPECTION BY DATE <br /> `2 7-?46 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 { <br /> - �''�Y S�•'�l- .�� , �� 7/72 1M <br />