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t. <br /> FOR OFFI <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678' 3 L <br /> APPLICATION FOR WELL CONSTRUCTIO`R OR PUMP PERMIT Permit No. 73 - .9 z I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name G p Phone 40 <br /> Address <br /> City sz TIC& <br /> Contractor's Name ��_ .,` „(lea License # <br /> --- k <br /> Phone tr��r��,3� # <br /> a <br /> TYPE of WORN (Check): NEW WELL / j DEEPEN /-7 RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR 2 -PUMP REPLACEMENT /-7 ` } <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 NZ <br /> Doshestic/private Drilled Dia, of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Worts Done <br /> PUMP REPAIR: State Work Done <br /> ESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> -- <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 /> (DRAW PLOY PLAN ON REVERSE SID <br /> FO EPARTIENT USE ONLY <br /> PHASE I ��j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S *FINSP I N <br /> INSPECTION BY DATE INSPECTION BY AT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION/ <br /> E H 1426 7/72 <br />