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p�L<� 1 JOAQUIN LOCAL HEALTH DISTRIC^ <br /> jFFICE USE:-;'- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J3- , <br /> �3_s96p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin. <br /> County Or�dJA nagce 1}o--,1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> S <br /> /61 , - ( K do �— / - k .�ur "i6 )1 <br /> JOB A99RS3&/LOCATION ��� s JaC b 1 X/ I�/f��:'.' ' S TRACT <br /> -Owner's Name � Sf Phone <br /> Address Z 1 (/' City <br /> r <br /> Contractor's Name ry�t/Q�f �1 fG/ t�S� License #U 70 Phone <br /> `-'TYPE OF WORK (Check) : NEW WELL �' DEEPEN /_/ RECONDITION /_� DESTRUCTION /-] <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,50� SEWER LINES PIT PRIVY 1",e <br /> SEWAGE DISPOSAL FIELD �-- C"SPAOL/SEEPAGE PI��f-OTHER \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private X Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z_ <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Other Rotary Type of Grout (c yhtf r <br /> Other Other Information <br /> PUMP INSTALLATION: ContractorAt,?f? <br /> Type of Pump /t,/.' -, a H.P. <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> rPUMP REPAIR: / / 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 /> SIGNE =6!-=.f .. . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE p �C <br /> ..ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI9N PHASE I / INAL 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 />