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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �.7 <br /> C <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 Ordinance No. 186 nd the Rules and Regulations of the San 'Joaquin Local Health District. <br /> /L� 15 MMR rtjr <br /> JOB ADDRESS/LOCATION {� <br /> S..0 ENSUS TRACT <br /> Owner's Name rxft ,6e 1`� C° moo. /YGr�► Phone <br /> Address '' Ceti p City <br /> Contractor's Na ,f - License # / Phone _ 617L 7* I <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ - RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR #7 PUMP REPLACEMENT /_ <br /> Other !/ / <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 oma,, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `I <br /> Industrial A Cable Tool Dia. of Well Excavation <br /> Domestic/private ! Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing i <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other IRotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done t Ales <br /> PUMP REPAIR: / / State Work Done t _ 771D�lAl�l� CA-511Y6- A <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate E 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-b lief. <br /> SIGNED W, INTLE , <br /> (DRA PL T PLAN ON RE SE SIDE ;. <br /> PHASE I 14K <br /> DEPARTMENT USE ONLY i <br /> I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: An� 77-411 <br /> PHASE II GROUT INSPECTION I <br /> P I �AT <br /> INSPECTION BY DATE INSPECTI BY 9 <br /> CALL FOR A GROUT INSPECTIONPRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM �4 <br />