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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> cry E. <br /> FOR OFFICE USE: 1601 ' Stockton Calif. <br /> Hazelton Ave. , <br /> : Telephone: (249) 466-6781 <br /> AP L CATION FOR .WELL CONSTRUCTION OR PUMP .PERMIT Permit No. <br /> THIS PERMIT EXPIRES- I YEAR FROM RATE ISSUED : <br /> Date Issued -!5iL n1 - <br /> (Complete In Triplicate) <br /> Application is hereby made"ton described. <br /> Joaquined. Thisoaallication istrict made inra permit complianceto construct <br /> with San Joaquin <br /> and/or install the work herein described. pP <br /> County Ordinance No. 1862 a:id! the Rules .and Regulations of the San Joaquin Local Health District. <br /> ` CENSUS TRACT Is <br /> JOB ADDRESS/LOCATION !a E 93I <br /> J ' i Phone <br /> Owner's Name AT <br /> City <br /> Address a1 ` <br /> �. License �� f 3 Phone �, ,5 ; <br /> E Contractor's Name <br /> ESTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN -/-7RECONDITION /p� REPLACEMENT <br /> PUNK' INSTALLATION /�I PUMP REPAIR / / <br /> Other' IXI <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CSPOOL/SEEPAGE PIT OTHER <br /> ES <br /> s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> t Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing . <br /> `Domestic/public 1 s- <br /> Irrigation 1 Gravel Pack Depth of Grot Seal <br /> u <br /> Other Rotary Type of Grout f <br /> Other Other Information' <br /> 5 <br /> 1 <br /> PUMP`INSTALLATION: Contractor H.P. <br /> k Type of PUMP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> PEST.IUCTION OF WELL: Well Diatieter <br /> Approximate-Depth-- <br /> Describe Material and Procedure <br /> I herebyagree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Within <br /> and the State of California pertaining to orregulating <br /> regulatiwill ng well cSant3oaquin•Local Health District a <br /> , <br /> after completion of my work on a new <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 and:. belief. <br /> P TITLE <br /> SIGNED <br /> (DRAW p T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHAS III/FINAL INSPECT ON <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> 4/72 1M C,C� <br /> E H x,426 <br />