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IA�) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave:; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 - r6 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued' Z� <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 Joaquir <br /> County Ordinance No. 1862 and the Rules nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name C <br /> Phone <br /> Address &1=4-� u City <br /> Contractor's Name nse # -24? oo Phone <br /> TYPE OF WORK (Check) : NEW WEL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> € PUMP INSTALLATION J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Y f <br /> r INTENDED USE TYPE OF WELL J � CONSTRUCTION SPECIFICATIONS <br /> Industrial . . _ Cable.-Tool —Dia.;--of-Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> r Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information F <br /> C <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done ; <br /> PUMP REPAIR: / / State Work Done <br /> f <br /> 1 M <br /> ,DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> _ — Describe Material and Procedure <br /> e <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 knowle and belief. <br /> r SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 3 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �� �7 <br /> TO GROUTING A <br /> CALL FOR A GROUT INSPECTION. PRIOR AND FINAL INSPECTION. � Lam" <br /> E H 1426 7/72 1M <br />