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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No.7-f- DD l <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE.'ISSUED . �Date Issued 2a _5' � <br /> I NGie- (Complete In Triplicate)al Health Zb3 <br /> Application is hereby madeto <br /> the <br /> eesSan Joaquin <br /> ihis <br /> quo <br /> struct <br /> and/or install the work herein dapplicatiori is made ra permit t <br /> made incompliancewithnSan Joaquin <br /> County Ordinance No. 1862 -and the Rules and Regulations of the SanCoca1 Health District. <br /> ) <br /> ! ENSKS� (�"'✓`� <br /> JOB ADDRESS/LOCATION ��" C <br /> Phone ' <br /> Owner's Name C�C� <br /> ' -,- 9'�F Y.2 � city <br /> Address .�� <br /> Contractor's Name <br /> r License # Phone ' <br /> -- <br /> :"—TYPE OF`WORK (Check} NEWy43ELL / I DEEPEN"/7 RECONDITION/ "I DE5TRLTCTTON / <br /> PUMP INSTALLATION /. / PUMP RE J/�UMP EPLACEMEI <br /> j Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> iCONSTRUCTION SPECIFICATIONS <br /> t. INTENDED USE TYPE OF WELL . <br /> Cable Tool Dia, of Well Excavation <br /> Industrial <br /> { Dia. of Well. Casing' <br /> Domestic/private _ Drilled <br /> Domestic/public <br /> Driven Gauge of Casing <br /> � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other' Other Information <br /> PUMP INSTALLATION: Contractor -' ` <br /> H.P. e? �� <br /> Type of Pump <br /> ;:� <br /> #' PUMP REPLACEMENT: / / <br /> State Work Done <br /> I <br /> PUMP REPAIR: / / State Work Done <br /> Approximate Depth <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of 'the-San Joaquin Local Health District; <br /> E uction.. Within.FIFTEEN DAYS: <br /> and the State of California pertaining to or regulating well constr <br /> k on a new well., I <br /> after completion of my. worhemlbeforefurnish <br /> puttingathaJoaquin <br /> inusecal. eThehabove <br /> District a <br /> WELL DRILLERS REPORT of the well and notify C <br /> information is true to t best of my knowledge and belief. <br /> � SIGNED .�.�u� TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR TMENT USE ONLY <br /> PHASE Tom, TE <br /> APPLICATION ACCEP BY <br /> ADDITIONAL COMMENTS: p I I INSPECTION <br /> ! PHASE II GROUT INSPECTION INSPECT <br /> INSPECTION BY DATE <br /> } CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br />