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USAN JOAQUIN LOCAL I-]ZALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.'; Stockton, Calif. <br /> Telephone:' (209) 466-6781 � r <br /> PLICATION FOR WELL CONSITRUCTION;.OR PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES ,.I�YEAXFROM DATE 'ISSUED =. -i-Date Issued ?7- <br /> (Complete-In- <br /> (Complete •In- Triplicate) <br /> Applicatipn„ri8..3hereb.yxmades.to ;the-sSan:jJoaqui.n 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.,,118862-•an " the'y:Rules-nand-'.Regulatioris`fof,,the SanlJoaquin Local Health District. <br /> i c s 3"C1-d2f A3 v;a'::la6 t. house 6xx eas- <br /> JOB ADDRESS/LOCATION ® ;i CENSUS. TRACT ` S <br /> Owner!s - <br /> NameJ, �� �",�r. f�rxs� ,RrG�i3iic3�3',l"nvd •�"�� . rsi�rft� s,; ,3 r , -Phoney -5" <br /> Address City _ <br /> Contractor's Name License # 771500- Phone ' ��g <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN "/ / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / Re lace p' p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS n ' <br /> t 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 ,�: �"' 'rTY`p e ofYGrout' <br /> Azri Service. _. Other Other Information <br /> PUMP INSTALLATION: Contractor San Joaquin Pump CMpany.INC. <br /> Type of Pump H•P• <br /> -a <br /> PUNK' REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter 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 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 owledge and bel' f. " <br /> a <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN-ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - DATE <br /> APPLICATION ACCEPTED BY 6e'-1Xz1 72,t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r/ DATE -7-T -A.- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />