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N 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. Z7-- /0 -2cD <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f <br /> (Complete In Triplicate) <br /> Application is here 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name Phone G 3 �_p S� . <br /> Address 3 S'�. �.. r City S 7c <br /> Contractor`s Nameve 4f O l t License # L2 2:t/Phone 3./8�33�3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> t PUMP INSTALLATION Z/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK/d&: SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Z <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 1 Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c, 4 -r*S i IVe H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> N.PESTRUCTION OF WELL: Well Diameter r r Approximate Depth 1 =------ <br /> Describe Material and Procedure <br /> r- �c <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 /> kafter 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 we-11 -in� use. The above <br /> information true to the best of my knowledge and belief. <br /> SIGNED TITLE C" <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTED BY DATE -2— <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHAA& II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> oft V <br /> INSPECTION BY DATE Z INSPECTION BY DATE, 1,915O119 <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> r <br /> E H 1426 7/72 1M <br />