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SAN JOAQUIN LOCAL BEALTH DISTRICT C`Y' <br /> FOY,"OFFICE USE: 1:601 E. Hazelton-'Aye:.;'. Stockton, Calif% <br /> 71 Telephone:`, (209_) 466-6781 <br /> APPLICATION FOR WELL CONS'TRUCTION`hOR PUMP PERMIT Permito. _/1�- 1, <br /> THIS PERMIT:EXPIRES •lkYEAR`I'FROM DATE ISSUED Date Issued <br /> J � t (Comp1,Ae `In Triplicate) E <br /> Ap iicatia:is�:herebyimade-vto :the.,)'San;Joaquin` Local'Health District for= a permit to construct <br /> and/or install the work herein described. Thi&• applic.ati•on, is made in compliance with -San Joaquin <br /> County:.Ordinance. No.i1862r:arid_the',Rules=:and`*Re'gulat'ions_: of the San Joaquin Local- Health District. <br /> "5; w ..+ {.•,' x <br /> X, <br /> JOB <br /> t,•r• •� �, r_ :t„S ',� a �//`,�J^., .i7 -`"t,�� .> a.-A E'�. .y - - - <br /> JOB ADDRESS/LOCATION. ���p-3 l i¢7L7�`71 Y�dL AdCENSUS' TRACT ' <br /> ”"1 r• w <br /> Owner's AName,:7-r,� i y l lir f �Cd'7 , c r, Phone 5_22 Z <br /> fax Cit /{?'c� O 657 G <br /> Address1 3 S Y <br /> ._._... <br /> Contra . - <br /> ctor's Name _ �1 � Pfi License .ark a3/,jPhones3,-�? <br />—.TYPE-OF_WORK (.Check) :_ NEW WELLDEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> a v ' PUMP INSTALLATION Z PUMP REPAIR / / PUMP REPLACEMENT /� -- <br /> a Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK-7� SEWER LINES F 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 6N <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 �; •,.r: Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION': X Contractor � tv-- <br /> „s x Type of Pump i r H.PW <br /> _ INj <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> 4 <br /> :DESTRU•CTION OF.WELL:, <br /> Well- Diameter-- �., _ _ Approximate Depth _v.__: _ <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 m work on a new well, 1 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS P T f t e well a y them before putting the well in use. The above <br /> information i t e o t of my -kno'wledge and belief. <br /> 5 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIB <br /> -... _ FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY JLjq" �= DATES 7O <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHA F AL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE <br /> CALLFOR A GROUT INSPECTION PRIOR.TO GROUTING AND .FINAL. INSP TION. _ <br /> E H 1426 - t +11.1, J. . 4/72 1M <br />