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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ��i Telephone: (209) 466-6781 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-3g3� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date rssued J_ <br /> (Complete In Triplicate) 4 <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' i's made in compliance with San Joaquin` <br /> County Ordinance No. 182 and the Rules and Regulations of the 'San Joaquin Local Health District. a <br /> JOB ADDRESS/LOCATION `L� 1f S- <br /> CENSUTRACT - <br /> � ' Phoria e <br /> Owner'a Name 0-4. !I� G It, 5 S C? <br /> -City. <br /> Address <br /> Address �'..._ <br /> Contractor's Name <br /> License # 7-6 S' Phone 4 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN / / RECONDITION /_� DESTRUCTION /� <br /> ¢PUMP INSTALLATION / / PUMA' REPAIR / / PUMP REPLACEMENT L <br /> Mother /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f X 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 /> Ij Other Other Information <br /> PUMP INSTALLATION: Contractor t ~ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done i <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: ,Well Diameter Approximate Depth <br /> i <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 milwork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o�f the well and notify them before putting the well in use. The above <br /> information is true toifthe best of my knowledge and belief. <br /> III, <br /> SIGHED <br /> LOT rLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j� <br /> APPLICATION ACCEPTED BY DATE 1(, <br /> ADDITIONAL COMMENTS: <br /> PHASE IIijGROUT INSPECTION PHASE-III. FINAL INSPECTION <br /> INSPECTION BY j DATE INSPECTION BY DATE <br /> �— 'CALL FOR.AIGROUT .INISPECTION PRIOR TO GROUTING AND FINAL INSP N; G(I <br /> E H 1426 -�. 7/72 IM <br />