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Q� ry SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /Pbo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �(-/6-7-1 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health Distract 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 1.t a Rules and Regulati ns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ''� CENSUS TRACT <br /> Owner's Name _ �O Q Phone'f</Z3Q3 <br /> Address p <br /> City <br /> Contractor's Name i License Phone��� <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLAT ON / / PUMP REPAIR PUMP REPLACEMENT /- <br /> Other ,crc.�rvly c9-c�7� �ci <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia, of Well Excavation ' , <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ; Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other _ Other Information <br /> PUMP INSTALLATION Contractor •., <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. <br /> / / State Work Done <br /> PUMP' �_ - - <br /> REPAIR:' '-.}", ;lam` 'S'ta`te 'Wor'k Done-&- <br /> (S <br /> -- -- (S <br /> DESTRUCTION OF WELL: Well Diameter Approximate .Depth <br /> T� 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 <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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) V �- <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I <br /> P►PPLICATION ACCEPTED BY DATE / -2 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E 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 7/72 1M <br /> E <br />