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SAN '-"kQUIN LOCAL HLALTH DISTRICT <br /> FOR OFYICEJ USE: 1601 E. zelton Ave., Stockton, C:01f. <br /> Tel..phone: (2A9) 466-6781 <br /> APPLICATION FSR WELL CONSTRUCTION OK !'U"U: PERMIT Permit No. ?Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / /t <br /> (Complete In Triplic:.te) <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 �73G S // // :,Jc f i �.:.,� �, ✓�( CENSUS TRACT <br /> Owner's Name p 0- C/-0 hJ�rc�c ���.� c_� Phone <br /> Address City <br /> Contractor's Name�`��-T�J</� t ��_! License �! •� ?Y1�Phone c�i�-'7�'7G <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN_ /7 RECONDITION /7 DESTRUCTION /-7 _ <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /V <br /> Other / / <br /> LISTANCE TO NEAREST: SEPTIC TANK SEWER LINES CIT 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 <br /> Domestic/private Drilled Dia. of Well Casing W <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r _ Gravel Pack Depth of Grout Seal <br /> Other _ ery Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumn H.P. _ <br /> PUMP REPLACEMENT: /YJ State Work Done r <br /> PUMP REPAIR: / / State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br />'r Describe Material and Procedure <br /> i _ <br /> 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> uction. Within FIFTEEN DAYS <br /> and the State of California pertaining to or regulating well constr <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 knowledg and belief. <br /> TITLE <br /> SIGNED r' ' i l -_- <br /> PLOT ON VERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> �- <br /> APPLICATION ACCEPTED BY _ -- <br /> ADDITIONAL COMMENTS: PRA �iI/F; INSPECTION <br /> PHASE II GROUT INS1'ECTIC'N _ INSPECTION BY <br /> ? DATE Z <br /> INSPECTION BY DATE <br /> CALL tOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT 7/72 1M <br /> E H 1426 <br />