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SAN JOAQUIN LOCAL UZALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Avd. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, IQ P � <br /> THIS PERMITEXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <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 L e& -&,a� lziwarj � CENSUS TRACT <br /> Owner's Name _ tCl�'T/J1 .y - Phone <br /> v <br /> Address City ti <br /> Contractor's Name � Ll .,�° Licensey# ff Phoned <br /> TYPE OF WORK, (Check) : NEW uWELj-/7/__.PE_E'?_FN" =/.---RECONI]iTION �DESTRUCTTON / .. r <br /> PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT ` s' <br /> Other /-7 <br /> � f <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 t 4G <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 Rotar..y Type of Grout <br /> Other i Other--Information <br /> 9 /! <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type.. H.P. <br /> yP P� - '1+' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well. Diameter Approximate Depth. <br /> k 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 Heaith'0istric:t a <br /> WELL DRILLER REPOR_ of the well and notify them before putting the well in use. The above <br /> informat1 is t o the best of my knowledge and belief. <br /> f <br /> E � <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEZ "7j <br /> F ADDITIONAL COM ENTS: <br /> PHASE II GROUT_INSPECTION_ PHAS III/FINAL INSPECTION <br /> 4 INSPECTION BY DATE INSPECTION BY DATE 3- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M ' <br />