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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �o7- <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued Lot - '?� <br /> 1 (Complete In Triplicate) <br /> olthe San Joaquin Local Health District for a permit to construct <br /> Application- is hereby made t <br /> This application is made in compliance with San Joaquin <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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Names <br /> Address <br /> License Phone &3&_a_6_a21 <br /> Contractor's Names <br />'r_-r-s�_� _ _ _ _ ..�.y_ _.._%�'�_=•`�'—.=-�.-?;+>.��._� _._.ate.-�,s,--._=�-�__,.__�-.-<-�.. s.,.-_.•_ �"-�a+ .�ua'Ps:�x�-...x.._r .1 <br /> TAPE OF WORK (Check) : NEW WE LL I/ DEEPEN_/ / RECONDITION /_7 DESTRUCTION /_T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other," <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOD/SEEPAGE PIT OTHER <br /> INTENDED'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool bia.°, of Well Excavation <br /> Industrial <br /> Dia. of Well Casing <br /> Domestic/private 1 Drilled <br /> Domestic/public ! Driven Gauge of Casing <br /> _ Irrigation "� Gravel Pack Depth of Grout Seal <br /> h Other Rotary Type of Grout <br /> Other Other Information <br /> F <br /> PUMP INSTALLATION: Contractor H.P. <br /> TyP ;e at Pump <br /> PUMP REPLACEMENT: /`7 State Work Done <br /> pUr(P�REPAIR•" : '"`- _' '//'^'`'State Work�'Do'ne '�"` <br /> j Approximate Depth <br /> �7ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> X hereby <br /> =and the Sagre t California"pertaining to or regulating well construction. within FIFTEEN DAYS <br /> after completion of my work'ona new well,notifyIthemwill <br /> beforefurnish <br /> puttingSan <br /> theJoaquin <br /> in use.cal HeTheh boveDistrict a <br /> WELL DRILLERS REPORT of theiwe11 and <br /> in€ormation is ' ue to the st of my knowledge and belief. <br /> k TITLE s <br /> SIGNED <br /> # (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> RASE I r DATE <br /> PLICATION 1ACCEPTED BY <br /> E ADDITIONAL COMMENTS: pHA E III NAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE y <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />