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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> kA Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IU- y�71 <br /> I' (Complete In Triplicate) <br /> Application is hereby made tolithe 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 /> .TOB ADDRESS/LOCATION / al. � Q Yt ad-*, CENSUS TRACT <br /> Owner's Name ✓ Phone <br /> Address r d-�' city <br /> •� � <br /> 701 <br /> R , <br /> Contractor's Name License 4i t 3 Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 12 <br /> Other / / .�. <br /> j <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 --5z <br /> Industrial .t Cable Tool Dia, of Well Excavation 1P <br /> Domestic/private �+.i Drilled- Dia. of Well Casing - <br /> Domestic/public i�Driven r Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other t Rotary Type of Grout _ 37 <br /> I Other `Other Information <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. 'A, y <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 beet of my kna edgep-and belief. <br /> SIGNED TITLE <br /> DREAW PLOT PLAN ON ALVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 7/72 1M <br />