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✓ -� SAN JOAQUIN LOCAL IiEALTH DISTRICT + <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7Z_/O_? 4e/ <br /> THIS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED Date Issued j� <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-applicati,on is made in compliance with San Joaquin <br /> County_Ordinance vft 1862- �h <br /> and` e .Rules .and Regulations of the YSan-JoIaquin Local Health District. <br /> /LOCATION ! �-yI ._L_/7t �r ENSUS TRACT <br /> Owner's Name �� �i'� .J� - - -- Phone <br /> Address i� City <br /> / - <br /> Contractor's Name License honez 7/T <br /> TYPE 'OF,.WORK (Check): NEW-WELL /-DEEPEN / / RECONDITION - DESTRUCTION ./ - -- <br /> PUMP INSTALLATION ZL,�- PUMP REPAIR / / PUMP REPLACEMENT /-T i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK (SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/,e?,9-{-CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private -,.jo-- Dnilled Dia. of Well Casing , � 0 <br /> __Atff�'omestic/public Driven Gauge of Casing <br /> Irrigation �y-rGravel Pack Depth of Grout Seal <br /> Other ` /_,.--Rotary Type of Grout K�►a7 ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 7'" <br /> F• Type of Pump A"' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and. Procedure <br /> n <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 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 BY DATE�� •� d—��- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE_//- <y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS CTTow , <br /> t E H 1426 7/72 IM <br />