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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltori Ave. ,' Stockton, Calif. <br /> Telephoner (209) 46 =6781 <br /> y. APPLICATION FOR WELL CONSTRUCTIONOR PUMP PERMIT Permit No 7 - <br /> THIS PERMIT EXPIRES -1'YEAR-'FROMIDATE >ISSUED Date Issued <br /> • (Complete 'In Triplicate) C� / <br /> Application.:;is,: hereby_made s.to the-,San!Joaquin. Local Health District for, a permit fc-4struct <br /> and/or install the work herein described. This- application is -made in compliance- with San Joaquin <br /> County Ordinance No:-,l8b2•i,ardi,the; Rules."and .Regulations,of! -the. San Joaquin Local—Health•District. <br /> • .�:. �'2,,.Q�.vV � �'l�r-' ���df+�'`- t'.i.:N:r . �.i Akt' .. .. <br /> JOB ADDRESS/LOCATION c CENSUS TRACT <br /> aa. }.Cr'wa: "S'• '.i _ .jEr] : t7S3 :; a, : -`.n. 'sx: �^ .. �/�l —7 <br /> Owner's`.Name~ { �,,, `°' ^ Y;its. .r 'y w <br /> Phone '. <br /> T — <br /> Adaress / / �►.� ,�- City <br /> Contractor's Name License 1&3Z C- Phone_7V t -l3 V�, <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN'/ -/ RECONDITION /_-7—DESTRUCTI0_N /_7 <br /> rP <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKZW%- T SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF W&IL CONSTRUCTION SPECIFICATIONS <br /> { Industrial le Tool Dia. of Well Excavation I ifN <br /> t. Domestic/private Drilled Dia. of Well Casing f® C l 4 G <br /> Domestic/public Driven Gauge of Casing l � f <br /> �rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout a zT / <br /> Other Other Information . t <br /> } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> p TRUCTION 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICAT N ACCEPTED BY DATES <br /> AD TIO COMMENTS <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> 17 ION BY DATE INSPECTION BY DATE <br /> ALLL OR A GROUT._INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 IM <br /> f j. <br />