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SAN JOAQ UIN LOCAL-IfALTH DISTRICT I <br /> For..' 'na USE c 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..7�4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued / 17 7� <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 described. - This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ?Is V'Af-CA,"_ CENSUS. TRACT <br /> 4 - Owner's Name �,��� - bo --- Phone <br /> Address City ' � <br /> Gontractar's-Name _ - r .._rt. ..� __ _Li.cense iD�� �tSZ Phoned -�lGb. <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION_,'/_/ DESTRUCTION /_ <br /> PUMP INSTALLATION REPAIR '/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 26 CESSPOOL/SEEPAGE PIT OTHER <br /> 5 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ C Cable Tool Dia. of Well Excavation <br /> T��Dome- stic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �:✓ <br /> Other w Rotary Type of Grout <br /> + Other Other Information ' <br /> PUMP INSTALLATION: Contractorc7.7c- -cc.� j <br /> Type',of Pump H.P. <br /> PUMP REPLACEMENT: / / �, State Work Done <br /> j PUMP `tEPAIR: -- / /- State Work Done <br /> ,DFO-TRUCTION 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 /> t informati°on is true to. the'.best of my knowledge and belief. I <br /> 3 k i <br /> 4 SIGNER ~ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I' <br /> APPLICATI`N ACCEPTED .BY,- � DATE 12- 73 <br /> ADDITIONAL COMMENTS: 3 <br /> P11AS It-GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE 1 ~ X73 INSPECTION BY DATE. -/ 2-Z-73 <br /> i I 'I <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 51731M <br />