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C V SAN JOAQUIN "LOCAL HEALTH DISTRICT { <br /> FOR OFFICE USE: 1601 E. Hazel ton�Ave. Stockton, Calif. j <br /> Telephorf6 ('209) <br /> APPLICATION FOR_WELLi--'6NSTRUCT.ION`OR PUMP PERMIT Permit No. ZAP: <br /> THIS`•PERMIVEXP RESf 3. 'YEAR PROM DATE ISSUED bate jssuedJ,�- _ <br /> {COVIO_te'.'In Triplicate) <br /> Application-=is- hereby` ii';ert0 the; San,Joaquin Local 'Health "Ilistric4t ''for �a 'permit 'to- construct <br /> and/or install the work herein described °'Th:s'applicateion is made in c`omplianee• with: San Joaquin, <br /> CountyOrdinaacei`No.. 1862 'and the `Ride`s and"' Regulation`s of the Sant Joaquin Local Health` District. <br /> W, Ax ,,, '�• ,1„ <br /> JOB ADDRESS/LOCATION ,`� i <br /> CENSUS` TRACT' <br /> d.' ?�t as.. } ,..:. b. i m _s e ...r.s. .:"r, �.-�3A <br /> Owner''tls "Name' r r J �3 r+ xAr. M k.. .:, .,, ;N <br /> Phone=' <br /> Address. fj . <br /> .o' LiJ.. w_ -City: <br /> ' . �� <br /> -Ci <br /> Contractor's Name LicenseWY 71Phon'e WJ34947-2 - <br /> I <br /> TYPE OF WORK (Check) :: NEW :WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTLATION PUMP REPAIR / /`PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> F +� <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER +�+ <br /> INTENDED ;USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /,4-%7*7. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /rj <br /> Irrigation . Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout c <br /> Other : Other Information •. <br /> 0 <br /> a <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /' / ' State 'Work Done p� <br /> PUMP REPAIR: � I <br /> / / jState ,Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllaws 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 I <br /> WELL DRILLERS REPORT of the.well and notify them before putting the well in use. The above <br /> information is true to the test of my knowledge and belief. <br /> SIGNED ' TITLE ' <br /> -__{DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY Y/zDATE <br /> ADDITIONAL COMMENTS: 7 . <br /> PHASE II G4QW".I14SPjibTjojV PHASE I I FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT "I13SPECTION .PRIOR TO GROUTING AND .FINAL INSPECTION. -�- - <br /> i <br /> E H 1426 <br /> 7/72 <br />