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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. 73-2213 U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5A 0/73 <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 CENSUS TRACT <br /> Owner's Name Phone <br /> Address ����` �' Qf city <br /> Contractor's Name jLicense # //633.LPhone <br /> .513 f <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN / / RECONDITION -/?. -DESTRUCTION/? -- - <br /> NT <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> b <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 /> --G1_- Domestic/private Drilled Dia, of Well Casing Ai <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal 3`0 • <br /> Other Rotary Type of Grout <br /> Other Other Information 8�1 OWAJ &I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP. REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED t TITLE <br /> DLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 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 1M <br />