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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 4'LrH <br /> 01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:.' (209),466-6781 <br /> TION FOR WELL CONSTRUCTION,'OR PUMP PERMIT Permit No. ��{ <br /> PERMIT EXPIRES 1;YEAR -FR.OM DATE 'ISSUED Date 'Issued 8 9- 7 i <br /> (Complete In` Triplicate) <br /> Application is�herebyimade <br /> 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:P1862 atidi,the.-Rules and .Regulations -of •the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATIONas CENSUS TRACT <br /> Owner!s Name” 4: f'S.r Q !�/4l' 'F Phone - . . <br /> Address d� <br /> _. .. - � City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ I DEEPEN/ / RECONDITION /_7 DESTRUCTION <br /> r PUMP INSTALLATION '/ ./ PUMP REPAIR '/ / PUMP REPLACEMENT I� <br /> � . OtherlII� `F <br /> DISTANCE TO NEAREST:- SEPTIC*TANK 'SEWER LINES - -PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDEDUSE € TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing ' <br /> Domestic/public " Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of. Grout Seal <br /> Other Rotary Type of .Grout - <br /> i" Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> ' ..Type of Pump H.P. • <br /> 'PUMP REPLACEMENT: } / / State Work Done <br /> lot <br /> PUMP 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 /> SIGNED ' TITLE ' <br /> t (DRAW PLOT PLAN ON• REVERSE SIDE). <br /> FO EPARTMENT US. ONLY <br /> PRASE ILAL <br /> 6 <br /> APPLICATION ACCEPTED BY DATE 8 <br /> ADDITIONAL COMMENTS: laz <br /> PHASEOUT INSPECTION PHASE II/FINAL INSPECT ON ; <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Lt�-. <br /> E- <br /> CALL FOR A GROUT. INSPECTICN PRIOR TO GROUTING AND.-FINAL INSP ION. ..� ti. �. �_ . T _. <br /> 4/72 1M <br /> Gam'- <br />