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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R6F-�'O1�1 ,ICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. �. <br /> x Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-33 94/ - <br /> 7E <br /> L- VII, <br /> � <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. 1862 and the Rules- and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATIONL C S CENSUS TRACT . <br /> I <br /> Owner's Name �L$ CC ��d�C - ` - Phone . <br /> Address '� city ' . t <br /> 4 <br /> Contractor's Name .- License Phone <br /> F ` <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION f_1 DESTRUCTION J-T <br /> PUMP INSTALLATION Pi,'MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other ./7 <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 42 Lj <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: f / State Work Done <br /> TRUCTION OF WELL: elrDiameter / Approximate Dep <br /> Describe <br /> Describe Material and Procedure <br /> I hereby agree to couiply 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 PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BY DAT <br /> ADDITIONAL' COMMENTS <br /> PHASE AWGROUINSPECTION PHASE Ii /FIN NSPECTION <br /> INSPECTION BY A/ ATE S'"= 2-`Z� INSPECTION BY DATES=2 &''`76 <br /> CALL FOR A GROUT INSPEC ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/733.M <br />