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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _7� <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued al� <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/LOCATION CENSUS TRACT <br /> Owner's Name 'Wn , r4Z� <� � :1�_ Phone 4, _ <br /> Address ` city c, e <br /> Contractor's Name , .5�; ��: ,v - -F - License # /Phone 2:,:?&. <br /> _ _ a Y <br /> TYPE OF WORK (Check); NEW WELL / 7 DEEPEN /_7 RECONDITION DESTRUCTION /_]' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Jai <br /> 14 j. other` <br /> DISTANCE TO NEAREST: SEPTIC IANK 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 4 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r' <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �� �` L ' H.P. <br /> PUMP REPLACEMENT: State Work Done ? kms.C�� l�r <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 t the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> --- , .FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY63114 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I I NAL INSPECTION <br /> INSPECTION BY DATE INSP CTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />