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.. . SAN JOAQUIN LDGAL REALTH DISTRICT OA-e- tom" , <br /> FOR rOFFICE SE: 1601 E. Hazelton' Ave. , Stockton, Calif. 3(4r"' al 17 <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION`-OR PUMP PERMIT Permit No. 7 z. 7 5 2— <br /> THIS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED Date Issued T—zl-7Z 1 <br /> (Complete In Triplicate) , <br /> Application' is,herebymade :to the San Joaquin Local 'Health:D.istrict for a permit to construct <br /> and/or install the work herein described. This: application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 andtthe_Rules' and Regulations of,the:San' Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION776 1 :CENSUS TRACT _3 { <br /> Owner' . N r ,} _ �"3�"— <br /> s ,Name",-'. ,, Phone <br /> Address 7 J ' <br /> r 7.2`/({city <br /> Contractor's Name <br /> License #.7,6 6Ci° - Phone `1(Z-'5757 <br /> -- , <br /> TYPE OF WORK (Check) : NEW WELL / /- DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 �' ? <br /> } PUMP INSTALLATION/ / PUMP REPAIR '/—/ PUMP REPLACEMENT /7 <br /> Other <br /> 4 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> —f�— Domestic/public Driven Gauge of Casing ` /Z <br /> Irrigation Gravel Pack 1 Depth of Grout. Seal. -- 6-- + <br /> Other _ Rotary A Type of Grout <br /> Other Other Information ' ' <br /> PUMP INSTALLATION: Contractor- � <br /> Type of� Pump H.P. <br /> PUMP REPLACEMENT: /_7 State'Work. Done: <br /> PUMP-REPAIR: / / State Work Done - <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure <br /> r <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 n ell, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPOT of e we notify them before putting the well in use. The above <br /> information i tr e t the y„1knowledge 'and belief. F <br /> SIGNED TITLE -ter <br /> y (DRAW P OT-PLAN ON REVERSE SIDE) <br /> ' FOR EVARTMENT-USE ONLY <br /> PHASE I <br /> APPLICA ION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ._ INSPECTION BYDATE ' 13.1 <br /> CALL_ FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. -��- <br /> E H 142b 4/72 1Mr '� <br />