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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE;PUSE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> d� Telephone:, (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L3 <br /> �� . . <br /> y; THIS PERMIT EXP19ES:"I YEAR FROM DATE ISSUED Date Issued L1-4-7 <br /> i ! "- (Complete In Triplicate) . <br /> Applicatiori' is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anal/or insJA' ll 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 A'-? CENSUS TRACT <br /> ir <br /> Phone <br /> Owner's Nat Al e-S x ✓ �' '"� <br /> City j <br /> Address <br /> ✓1 License 46 73•!�'Phone24 <br /> Contractor".s Name / ate <br /> TYPE OF WORK (Check) : NEW WELL /7 <br /> DEEPEN -7- RECONDITION /� DESTRUCTION /? <br /> PUMP INSTALLATION �/ PUMP REPAIR / PUMP REPLACEMENT /? F <br /> Other <br /> 1 DISTANCE Tb NEAREST:. SEPTIC :TANK SEWER LINES PIT PRIVY <br /> SEWAGE FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Indulstrial Cable Tool Dia. of We 11 Excavation . <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven' Gauge of Casing <br /> Irrigation t Gravel :Pack Depth of Grout Seal <br /> s Other I Rotary Type of Grout <br /> Other Other Information + <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump 1 H.P. <br /> I PUMP REPLACEMENT: / / . State Work Done <br /> p /% State Work Done <br /> Approximate Depth <br /> _DESTRUCTION -OF WELL: Well Diameter <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 /> i <br /> after coml:pletion pf my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIAERS REPORT of -the well and no -fy them before putting the well iri use ':The above <br /> information is true .to the Wiest of .my`knowledge and­be iefLE <br /> . .. <br /> SIGNED <br /> (DRAW L T PLAN ON REVS SIDE <br /> DEPARTMENT USE ONLY <br /> r PHASE I ✓r DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:- PHAS III FINAL INSPECTION <br /> ill PHASE II G XNSP CT NBY DATE <br /> JINSPECTION BY 3.DATE _ INSPECTION <br /> CALL FOR A GROUT INSPECTION .PRIOR• TO GROUTING AND FINAL INSPECT N. <br /> 7/72 114 <br />