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1 f/ t <br /> V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POE OFFICIO USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ina-- i9,*-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-2-74, <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 application is made in compliance with San-Jiaaquin <br /> County Ordinance No. 1€i62 and the Rules and Regulations of the San Joaquin Local Health Disprict. <br /> JOB ADDRESS/LOCATION _1olr CENSUS TRACT <br /> Owner's Name !' �� �- Phone3(9 G3 T7 <br /> Address City <br /> Contractor's Nam<Zft�� % License #AP3 '-3Phone Y3-13Y? <br /> TYPE OF WORK (Check): NEW WELL / j DEEPEN '/_/ RECONDITION f-1 DESTRUCTION /7 <br /> PUMP INSTALLATION j / Pi,`MP REPAIR J / PUMP REPLACEMENT /-7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK]b(--3 SEWER LINES PIT PRIVY _ <br /> SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> :;�— amestic/private Drilled Dia. of Well Casing 2 <br /> Domestic/public Driven Gauge of Casing --1 96--- <br /> _,,,:f�Irrigation Gravel Pack Depth of Grout Seal S' (I �^ T <br /> Other Rotary Type of Grout I< <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: J J State Work Done : <br /> .DFCTRUCTION OF WELL: 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 /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE "• ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IPSPECTION PHAS III/FINAL INSPECTION I <br /> INSPECTION BY &OvIATE 7 L INSPECTION BY ✓ DATE <br /> ,�:CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W G4 <br /> Fl H 1426 5/73 ix <br />