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-1 <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT �. <br /> "FOR OFFICE USE: - 160 E. Hazelton Ave. ,Stockton , Calif. <br /> Telephone: (209) ,466'-6781 <br /> P CATION FOR 'WELL CONSTRUCTION OR PUAT PERMIT Permit No. <br /> HIS .PERMM.EXPIRES; 1 YEAR FROM DATE ISSUED Date Issued 03171/ <br /> (Com71 <br /> plete Iii, Triplicate) ��5-- 7 j <br /> Application, is her by -made to !the.-San, Joaqui`n,Lo6al 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 a/nd the,Rules and Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT J7- d <br /> Owner,'s-Narce C7 /l/ L G°MF- " Phone 0 3 `",1 <br /> Address fit /ter eco �.� Ile City ��/ti��'�'cesL <br /> Contractor's Name /tel I L n License # Phone ' <br /> d <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 47a SEWER LINES Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ! U CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Ilia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ` Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> e <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 t ;well and notify them before putting the well in use. The above <br /> information is ue to t tknowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I •- <br /> APPLICATION ACCEPTED BY J DATE/ ��_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,.. DATE ZOO-�� _ INSPECTION BY `�i ..a DATE 2,3 ZZ--.-. <br /> CALL YOR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �. <br /> E H 1426 4/72 iM <br /> :f <br />