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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z_-10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �k • (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 Joaquin <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � t 4- 'o 4z,-_TIV o /51 A 1Z. CENSUS TRACT S <br /> 434 <br /> Owner's Named ' LING., Phone 3/ 3 3 <br /> t Address 1 r y City .21 CA f-I& . <br /> Contractor's Name A Rj bSS i - License �otl Phone 7,j,-t0s` L - <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> C Other / / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Na <br /> Industrial Cable Tool+ Dia. of Well Excavation /Z" r <br /> ! A Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing IL <br /> Irrigation Gravel Pack .Depth of Grout Seal s a <br /> Other Rotary Type of'Grout <br /> Other Other Information S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> L-_PUMP~REPAIR: _ �__/7/. State .Work Done <br /> ,DESTRUCTION-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 ITLE <br /> (D 4J PLOT ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY_ "( 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E R 1426 7/72 1M <br />