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SAN JOA4 UIN LOCAL HEALTH DISTRICT <br /> FOL -OFFICE USI:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a:wl ? ♦ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS <br /> o. - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l -..2r/-73 <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 worts 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 /> 5. N .. CA,,j 4��A--,ate // r4-� c - YoD-2Y <br /> JOB ADDRESS/LOCATION a.ct msf d C- CENSUS TRACT". <br /> Owner's Nance -- --�� �C.L �.14 �[.�' (_ Phone <br /> s Address G 7 �- � _Aj_.(YayYI�. f2� City ­ Q(IC-L" <br /> Contractor's Name 9' OW " } . , License # /g3 Lrhone <br /> ' Y <br /> k <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION f_1 DESTRUCTION /_7 Ci <br /> PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT 67( <br /> PUMP <br /> Other <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TAivK SEWER LINES PTT 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information, <br /> i <br /> k PUMP INSTALLATION: Contractor <br /> Type of Pump H.P., <br /> PUMP REPLACEMENT: . ! State Work Done a f �.".�.. i ��� <br /> PUMP 'REPAIR: / / State Work Done <br /> i ;DFIRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> E 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 /> j 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The ,above <br /> ainformation is true to the best of my knowledge n elief. <br />{ SIGNED zatx LE <br /> f (p id _ 'PILAN ON REARSE SIDE_) <br /> FJR TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BZ2zDATE ZZ 32> <br /> ADDITIONAL C=ENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z$� <br /> y.,. CALL,FOR,A�GROUT INSPECTION PRIOR..TO GROUTING AND FINAL_INSPECTION. <br /> L� u IL.7r 5/731M <br />