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SAN JOAQUIN LOCAL ITEALTH 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.J� <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED.. Date Issued Z15:1-.7-el-72 <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/LOCA ON CENSUS TRACT S `� <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name ,t '' License #� -7/0joy Phone362'IZZZ I <br /> _ F <br /> TYPE OF WORK (Check) ; NEW WELL/DEEP N. / / RECONDITION /-7- DESTRUCTION /-7- <br /> PUMP INST LA ION 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 Ni <br /> PUMP INSTALLATION: Contract �^ <br /> Type of umP H.P. Q <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 /> 7 <br /> SIGNED C TITLE <br /> (DRAW PLOT 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 BYQ 74/72 <br /> E � .11-1L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1M <br />