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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner , (209) 4606-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? q 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 72,- <br /> (Complete <br /> L(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 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 /> f %eJA,qLOU " <br /> JOB AAM S/LOCAT.�ION q + CENSUS TRACT <br /> (F, <br /> Owner.1 s Name Phone <br /> Address City <br /> Contractor's Name License #/L23 ,3 Phone3 -.S 3 c i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN, / / RECONDITION-4/ DESTRUCTION /_ <br /> PUMP INSTZALLATION '/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD4 CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> INTENDED USE TYPE OF,-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public, Diven Gauge of Casing <br /> !-Irrigation _ f .R. Gravel -Pack. " _ DeptYj off Grout Seal <br /> Other Rotary „ Type of Grout <br /> Other f Other Information <br /> PUMP INSTALLATION: Contractor ti <br /> Type of Pump '"' H.P. <br /> . i <br /> PUMP REPLACEMENT: / / State Work Done: <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF HELL: Well Diameter } ' Approximate Depth <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 /> 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 i TITLE <br /> I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR-DEPARTMENT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />