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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v01 E <br /> 166 E. Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 3-3 <br /> Date Issued .3- _3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ---z <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin LoapplicationealthDistmade inrcompliancea permittwithnSan Joaquinl, <br /> and/or install the work herein des <br /> County Ordinance No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> G' I � CENSUS TRACT <br /> JOB• ADDRESS/LOCATION G�_ S r <br /> Phone <br /> �O/I <br /> Owner's Name <br /> • `� �X 2 rl - city �P <br /> Address - Q, . ;{ , u r ', <br /> Phone <br /> U� License #E <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL <br /> DEEPEN RECONDITION_ PUMP REPLACEMENT/� DESTRUCTION I�T - <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY OTHER <br /> LL <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial I _ Cable Tool Dia. of Well Excavation <br /> -54 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Rotary Type of Grout <br /> Other' _/Z�16--- Other Other Information %3 -�� 0N <br /> 11111,111 <br /> W IDE <br /> PUMP INSTALLATION-. Contractor H.P. <br /> Type lof P1fiDP <br /> t <br /> PUMP REPLACEMENT: I I <br /> State Work Done <br /> PUMP REPAIR: / / ,j State Work Done <br /> s Approximate Depth _ <br /> ESTRUCTION OF WELL: We11 Diameter <br /> Describe Material and Procedure. - <br /> of ' <br /> j <br /> i I hereby agree to Comply with all laws and regulations the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating .wel_l construction: Within FIFTEEN DAYS <br /> } after completion of my work on a new well, I will fur'nish' the' San Joaqui.n 'Loca'1 Health District a <br /> WELL DRILLERS REPORT of the sell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge an <br /> " TITLE' , <br /> SIGNED PLAN ON REVERSE SIDE <br /> (DRAW PLOT <br /> i FOR DEPARTMENT USE ONLY . <br /> PHASE DATE R/U - <br /> APPLICATION ACCEPTED BY <br /> t ADDITIONAL COMMENTS: 1 . -,> IP SEaIIFINAL' INSPECTION <br /> PHASE II GROUT INSPECTION 7� INSPECTION BY DATE <br /> E INSPECTION BY -_ DATE <br /> CALL FOR A G NSPEGTION PRI TQ GROUTING AND FINAL INSP ON• 7/72 1M <br /> ' E H 1426 ,; . - <br />