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n <br /> •�i-' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � .s� <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 describd. This application is made in compliance with San Joaqui <br /> County Ordinance No'. '1862 and,� the Rules nd Regulations of rhg San Joaquin 'Local Health District. <br /> JOB ADDRESS/LOCATION -3 � T,4/ ! ` V <br /> CENSUS TRACT <br /> Owner's Name J��'tx AL._'�I+2 Ph one V� '"K/ 24-- - <br /> �l <br /> Address CL��� City I <br /> Contractor's Name License # Phone,, <br /> TYPE OF---WORK(C-he•ck)-:—NEW-WRLL—/ DEEPEN-/ /�R•EGONDITION,/_�-DES TRUCTION /�— <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other \ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (� <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> hC Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -- --Domestic/public Driven Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> Son Joaquin Pump Co. <br /> PUMP INSTALLATION: Contractor P dAMWan of San Joaquin Sulphurce,� <br /> t Type of Pump 54J,f r taSttA L� . r r►eman H.P. eeo <br /> " ai, California95Z40 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. / State Work Done <br /> ,DESTRUCTION OF WELL: Well-Dlamefer Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and -regulations of the San-Joaquin- Local_ _Health_ District <br /> and the State o a gu ating well construction. With n DAYS <br /> after complet wor on a new well, I w San Joaquin Local Health District a <br /> WELL D LLERS REPORT of the well and notify them before putting the we (The above <br /> information is true to the best of my knowledge and belief <br /> SIGNED <br /> .t•�L.` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I +. <br /> APPLICATION ACCEPTED BY - -- DATE Z p a2/ ! <br /> ADDITIONAL COMMENTS: -- - <br /> PHASE I ROUT INSPECTION PHASE III FINAL S.INSPECTION BY OvZ <br /> DATE INSPECTION BY DATE ,1 <br /> C,4LL-FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H,1426 7/72 1M <br /> �.. <br />