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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton,Ave:, Stockton,- Calif. <br /> Telephone: (209) 466-6781 <br /> 4 PLICATION FOR WELL CONSTRUCTION ,�OR PUMP PERMIT Permit No. <br /> E <br /> THIS —PERMIT—EXPIRES 1.YEAR FROM DATE ISSUED Date Issued L C 7 <br /> (Complete In Triplicate) <br /> Application,is .he.rebytmade to :the San�Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. Thisapplication is made in compliance with San Joaquin <br /> County Ordinance. Na 1862 and the Rules>ategulations o t Saaquin Local Health District. <br /> JOB ADDRESS/LOCATIONfVSfn� <br /> k �- -& ? Al Sa `7 U/-/. 01' CENSUS TRACT $ 7 <br /> Owner.'s Name) IL. - Phone <br /> Address �CaG t - - a c[•t[. _ [j pie N r�_� City AG L"A <br /> Contractor's NameLicensed 2�s /Phone <br /> TYPE OF WORK (Check) . NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .`dao ., SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL`/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <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 /> s Other Other Information , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Zveo_S;w.,/3 � C H.P. /P /{l <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: - Well Diameter / _ App-r-oxmarerDep.th-y3-yam• �— <br /> Describe Material and Procedure t# = <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 /> f 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 /> (D LOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY - <br /> f APPLICATION ACCEPTED BY e DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,r-17-7 <br /> i CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E 1426 " 4/72 1M <br />