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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) '466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: X37 i <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 wits; San Joaquin <br /> County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION } . �/� ,L <br /> - °�� _ iYo-r'7' t i�� 4,q& CENSUS TRACT 17,3–o2te..o I? <br /> N I <br /> Owner's Name Q ,r Clrrf Phone <br /> Address . _ F r�I a� r* 0 tec _ 0 City <br /> Contractor's Name �� - License # /� 3 72*hone - <br /> TYPIC OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT /i <br /> Other / / — <br /> W <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �1 <br /> INTENDED USE TYPE OF WELLA <br /> CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. o€ Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing I <br /> Domestic/public _ Driven Gauge of Casing r� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> e <br /> PUMP INSTALLATION: Contractor <br /> e �. <br /> Type of Pump cf� ✓ H.P. <br /> PUMP REPLACEMENT: / / State Work Bone <br /> PUMP REPAIR. / / State Work Done i <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 Says 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 my know and belief. <br /> SIGNE ®f� TLE <br /> y <br /> W QT LAN ON R FRSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALM. F'OR_A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br /> E H 1426 7/72 1M 'E <br />