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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L 4 � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 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 <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 /> 1� <br /> M JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone PA, ,Z ~ <br /> Address .� , <br /> � .S City 7-�2G/KiGIY. <br /> t Contractor's Name if 14 ,1- Y, I/ LZ 4:,`:. ('Q License 4t GLGz Phone <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INST LATION / / 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 /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _Drilled Dia. of Well Casing r� <br /> Domestic/public Driven Gauge of Casing /Z <br /> Irrigation Gravel Pack Depth of Grout Seal 5`(j <br /> Other - Rotary Type of Grout 1'4/9 y <br /> Other Other Information ^()Mp �Y aL Ujjy[-%� <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> PUMP REPLACEMENT: r. <br /> / / State Work Done <br /> PUMP REPAIR. / / State Work Done <br /> J)ESTR_U_CTION 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` orJregulating'well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new welt, 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='and­belief. <br /> SIGNED . ~r- TITLE <br /> (DRAW PLOT PLAN_ON_REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED_BY._ K- <br /> ADDITIONAL COMMENTS: ,. ~ <br /> PHASE II GROUT INSPECTION PHAS I/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. y <br /> E H 1426 �' µ y 7/72 <br />