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4 <br />_ SAN JOAQUIN LOCAL IiEALT'H DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone: - ('209) 466-6.781 r <br /> APPLICATION FOR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES "1 YEAR FROM- DATE 'ISSUED Date Issued ' a Y <br /> (Complete In Triplicate) <br /> ApQlicatian•,is..,hereby .macie .to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application ismade in compliance with San Joaquin <br /> County Ordinance No.? 1862 .and .the. Rulds and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION [,( J�� �, u �� CENSUS TRACT OZ.3--lsk^37 <br /> //r <br /> Owner's�Name �. 1 � x..r_` r 2.i � Phone <br /> Address 2. ,[ r%r4 — .� CSU City <br /> Contractor's Name (J ]� ` + J(,t� / / °— License UIX1760 Phone <br /> 'TYPE OF WORK (Check): NEW WELL// ' DEEPEN /7 RECONDITION F7 , DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION tTl PUMP REPAIR/ /, PUMP REPLACEMENT /-7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CSPOOL/SEEPAGE PIT OTHER <br /> 'L�= -'--YJ .�F vC�L/? � ✓f�/�J..^rf J ���_�J��I�� ..F� � -. .r� ::aa'.� r � 1. , <br /> INTE14DED USE--"'-- i TYPE OF WELL ,. . CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled" Dia. of Well Casing �I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel iPack Depth of Grout Seal. .r <br /> Other Rotary Type of Grout <br /> Other Other Information' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` 4. H.P. <br /> :PUMP REPLACEMENT: / IN/ State Work Done , <br /> A iM 1 <br /> PUMP REPAIR: S to Work Dane <br />;pESTRUCTION OF WELL: Well Dia m to Depth <br /> Dl�scribe`Material ,and Procedure <br /> i <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 wel1, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT .6f the well and notify them before putting the well in use. The above <br /> information i true to .tfi�e_ st of my knowledge and belief. <br /> SIGNEDy��s { /` : I , TITLE <br /> !M (DRAW.PLOT PLAN. ON REVERSE S.ID ) s <br /> I <br />,PHASE I FOR DEPARTMENT. USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY . � '. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL-INSPECTION <br /> INSPECTION BY DATE INSPECTION'BY' :!T- - DATE/ /(, -7 y/. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ECTION <br /> E H 1426 ; ��� 4/72, 114 <br />