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f _ <br /> 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. 7- 7-P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S 3 a 7-3 <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 'O�e <br /> CENSUS TRACT _ <br /> Owner's Name � Phone <br /> � <br /> _ City <br />' Contractor's Name <br /> Address 31 . / License # Phone ,3 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <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 /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> Other Rotary Type of Grout ' <br /> Other Other Information Q <br /> PUMP INSTALLATION: Contractor �� /// !� <br /> Type of Pump H.P. �+ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done <br />_DESTRUCTION OF WELL: Well Diameter 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the we in use. The above <br /> information is true the best of my knowledge and belief. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSES E) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Zw,,t4q, <br /> APPLICATION ACCEPTED BYDATE 1��J- 7Y <br /> - <br /> PHASE <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />