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SAN JOAQUIN LOCAF'4'1-MA17rH DISTRICT i <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. Z{/".„_2�� <br /> Date Issued <br /> THIS PERMIT EXPIRES l YEAR 'DATE :ISSUED L <br /> (Complete In- riplicate) <br /> A plication is hereby.'made`"toithe San~JoaquThisoapplication isealth madeinr -a permit compliancetwith construct 1 <br /> P <br /> and/or install the work herein described. This app <br /> County Ordinance No !1862 and-the :Rule's and Regulations of the San Joaquin Local Health District. <br /> .� r � � .- CENSUS TRACT <br /> JOB ADDRESS/LOCATION o 11 c <br /> 'Phone ' <br /> Owner's .Name . .. �_ <br /> Cit <br /> Address <br /> - License �� Phone <br /> Contractor's Name lG d C, <br /> TYPE OF WTION <br /> ORK (Check) : NEW WELL ICI DEEPEN �I_I RECONDITION / PUMPEREPLACEMENT�/? <br /> PUMP INSTALLATION / I PUMP REPAIR "/ I <br /> Other I I <br /> . �� SEWER LINES PIT PRIVY <br /> OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK v� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL a, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ,r <br /> x. <br /> Driven Gauge of Casing <br /> Domestic/public V <br /> Gravel Pack Depth' of Grout Seal �S O <br /> Irrigation <br /> Other �_ Rotary Type of Grout ;� i -71-1i'� <br /> Other Other Information <br /> y <br /> G PUMP INSTALLATION: Contractor �! H.P. a— / <br /> Type of Pump <br /> PUMP REPLACEMENT: ' State Work Done <br /> PUMP REPAIR• g / / Sate„Worms one <br /> Approximate Depth <br /> i ,DESTRUCTION OF WELL: Well Diameter ��� <br /> Describe Material and Procedu� ct � S <br /> n Joaquin Local ealth District <br /> I hereby agree to comply with all laws and regulations of the Sa q <br /> and the State of California pertainingeto orre <br /> re I furnishwell <br /> the cSantructionJoaquin. Local hHealthTDistrict a <br /> ! after completion of my work on a new <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i information is true to the best of my knowledge and belief. <br /> l TITLE l � <br /> SIGNED /Y ! - ~! (DRA PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED„ BY <br /> ADDITIONAL COMMENTS: ' PHASE IIIIFINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY <br /> r INSPECTION BY <br /> 4 CALL FORA GROUT INSPECT PRIOR TO GROUTING AND FINAL INSPE ION. 4/72 <br /> E H 1426 <br />