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SAN JOAQUIN LOCAL HEALTH <br /> FOR OFFICE USE: 1/1601 DISTRICT <br /> E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No._7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r ?-7�3 <br /> (Complete Triplicate) <br /> Application is hereby made to the San Joaquin Local 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 Re Mations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT �S'f <br /> Owner's Name <br /> Address <br /> City <br /> Contractor's Name j <br /> Licens , <br /> t#61LS-� Phone, _c_ -r16y6 <br /> I� <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /% RECONDITION /_% DESTRUCTION /� I <br /> PUMP INSTALLA ION.:: /—/ PUMP REPAI / / PUMP REPLACEET /_ <br /> Other Y/ <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 <br /> Domestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing <br /> 9---�_Irrigation Gravel Pack Depth of Grout Seal �# <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor G <br /> Type of Pump H.P. <br /> _ Az ME— <br /> PUMP REPLACEMENT: / / State WorkDone„ <br /> PUMP REPAIR: /J(/ State Work,Done ; 9 <br /> € � Go o <br />,DESTRUCTION OF WELL: Well Diameter 1 } <br /> 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 Disterict 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. r <br /> SIGNED ti-.� ' ., -.� . :k r �\, .,. ,• ' � <br /> TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE } <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS., DATE,7 <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ., 7/72 1M h <br />