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SAN JOAQUIN LOW 'HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued ;12117X <br /> # (Complete In Triplicate) <br /> Application is hereby made tolthe .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 /> JOB ADDRESS/LOCATION 69 /V. CENSUS TRACT <br /> `` F <br /> Owner's Name Phono,34—r— <br /> Address City <br /> 4 <br /> _ F r <br /> Contractor t s Name_ _ - _ �Uw� L�- w �.�1! sLicense--l� hone <br /> �� <br /> - <br /> TYPE OF WORK- (Check) : _NEW WELL / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- � <br /> PUMP-INST TION / PUMP REPAIR/. / PUMP REPLACEMENT /� ` <br /> Other +/ <br /> �f <br /> DISTANCE TO NEAREST: SEPTIC TANK : SEWER-.LINES PIT PRIVY <br /> SEWAGE-D'TSPOSAL FIELD r CE SPOOL/SEEPAGEiPIT OTHER <br /> of ` <br /> a <br /> INTENDED USE TYPE OF WELL CONSTRU.CTIONISPECIFICATIONS v <br /> Industrial 17' Cable Tool-- -. Dia: of Well- Excavation <br /> Domestic/privatex Drilled = Dia: of Well Casing <br /> Domestic/public # ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth. of. Grout.-Seal' _ <br /> Other 0 Rotary Type of Grout...,,- <br /> - <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / -State -Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well'biameter Approximate Depth <br /> Describe Material and Procedure <br /> Ihereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br />• and the State ,of California pertaining tojor regulating well construction. Within FIFTEEN 'DAYS <br />, after completion of my work on a ne'a-well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we and notify them before putting the well in use. The above <br /> information is ue to the be of my knowledge and belief. - <br />, SIGNEDTITLE OE <br /> '(DRAW P OT PLAN ON REVERSE SID <br /> TPR DEPARTMENT- USE-ONLY <br /> PHASE I ! h <br /> APPLICATION ACCEPTED BY y - DATE <br /> tADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ,_ _ __ r . PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AE2 DATE ;�J1.� <br /> CALL FOR A GROUT INSPECTION' PRIOR TO GROUTING AND FINAL INSPECTION; <br /> E H 1426 7/72 1M <br />