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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave.`, Stockton, Calif. ���(� �y+ <br /> Telephone: ' (209) 466--6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: <br /> t <br /> _ THI11 S PERMIT EXPIRES I YEAR FROM DATE ISSUED- Date issued <br /> -7�.� :, .4 <br /> %+-�J SIQ.�,i. �I'�(Complete In Triplicate) pS�_ � j ��� <br /> Ij <br /> Application ie+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. 1`862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION ! rIAV <br /> f- L' Q CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> Z_.049r Cit <br /> i y <br />( Contractor's Name [/SLG ��i�Gr�,� r License # <br /> I Z .11/ Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN <br />' �� _/ RECONDITION /-7,�DESTRUCTION /�]` <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> OtherPUMP REPLACEMENT /? <br />`. q/ / " <br /> iW,, <br /> DISTANCE TO NEAREST:` SEPTIC TANK _ SEWER- LINES PIT PRIVY <br /> -' 46 : ` -SEWAGE DISPOSAL FIELDi <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> 1 <br /> Industrial Cable Tool Diad of Well Excavation /,0, <br /> Domestic/private Drilled Dia., of Well Casing " ' <br /> Domestic/public € Driven , <br /> Gauge of Casing _ <br /> --��Irrigation Gravel Pack Depth of Grout Se_al <br /> Other Rotary Type of Grout = <br /> Other Other Information <br /> PUMP INSTALLATION Contractor # <br /> Type of Pump ¢ H.P. <br /> ; <br /> PUMP REPLACEMENT;' / / State Work Done F <br /> PUMP REPAIR: d <br /> Stiate Work Done :'•' <br />.PESTRUCTION OF WELL; Well Diameter ` ' <br /> • �' Approximate Depth -4 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and-,regulations of the San Joaquin Local Health District i <br /> and the State of California pertaining to or regulating -well construction. Within FIFTEEN DAYS k <br /> after completion of my work ori a new well, I will furnish ,the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before iputting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED -- _ TITLE <br /> (DRAW_PLOT-�PLAN, ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: `9 <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY -_ DATE INSPECTION BY DATE --7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. Ah�j <br /> ir <br /> E H 1426 7/72 1M k"� f <br />