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i <br /> ,a� Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> +�6 Telephone: (209) 466-6781 <br /> LICATION FOR'4JELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 73- sy9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> } (Complete In Triplicate) <br /> Application is hereby made tol 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's. 2862 d Ru ewand RemulAtions of the San Joaquin Local Health District'... <br /> JOB ADORE&S/LOCATION f (� 1-11 G CENSUS TRACT <br /> Owner's Nates �GtPre 4 Phone <br /> Address City <br /> Contractor's Name / .S' Ji75 License Phone �� <br /> TYPE OF>W'ORK (Check) : NEW WELL S DEEPEN -RECONDITION /77, DESTRUCTION /_7 i <br /> i, PUMP iNST LATION &_7 <br /> PUMP REPAIR I -PUMP PUMP REPLACEMENT /? <br /> a <br /> Other ; <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES 1�12PIT PRIVY V&LA41 <br /> SEWAGE DISPOSAL FIELD CESSPOOLISEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V� <br /> Industrial = :I Cable Tool Dia. of Well, Excavation <br /> Domestic/private I Drilled. ,' Dia. of Well' Casing <br /> Domestic/public I Drivenry Gauge of Casing <br /> - - - <br /> _ Irrigation Gravel Pack. Depth of Grout Seal <br /> t — Other, ` Rotary Type of Grout <br /> "l Other Other Information <br /> s f <br /> PUMP INSTALLATIONS contractor <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT: / / "State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> 1SIGNEDAlf TITLE [J� <br /> f (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE ' <br /> ADDITIONAL COMMENTS: t <br /> PHASE II PROUT INSPECTION PHASE III FINAL INSPECTI N <br /> 1INSPECTION BY DATE J-- - 2,3 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 T _ "� - 7/72 1M� <br />