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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> C <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 - .SDO Lc1, <br /> k THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3^ s9 <br /> 7� <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 Joa uiJl <br /> County Ordinance No. 1862 and...the,.Rul-es and Regulations of the San Joaquin Local. Health District. <br /> JOB AibfflM /LocATION ,esus TRACT 103- Ze_OZ <br /> Owner's Name 1 <br /> G Phone <br /> Address <br /> City <br /> Contractor's Name <br /> f e License #WW Phone14 ' <br /> G TYPE OF WORK- (Check): NEW WELL DEEPEN / / RECONDITION /� DESTRUCTION /-7 <br /> PUMP INS A N / / PUMP REPAIR / / PUMP REPLACEMENT <br /> E Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC ,TANTS " - SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD � - pp <br /> /SEEPAGE PTT _ `1- OTHER --� <br /> INTENDED USE TXPE OF WELL $ <br /> CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> „ Domestic/private Drilled Dia, of Well Casing <br /> AP <br /> Domestic/public I Driven Gauge of 'Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout f <br /> 1 Other Other Information f <br /> J <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump ~� <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure e-- <br /> I hereby agree to comply with [all laws and regulations of the San Joaquin Local Health District <br /> and the State o€ 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 to the best of my knowledge and belief. <br /> SIGN TITLE" <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,ter <br /> APPLICATION ACCEPTED BY C, DATE el <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> l <br />