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s , <br /> T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.�,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .-02� <br /> s <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 �L� 7S 1 �S ©/��"S CENSUS TRACT <br /> Owner's Names 64,Ke y cdeaO5007-Al S, Da- A o VSE� Phone L ����� <br /> AddressCity <br /> Contractor's Name ,4 U n� License # Phone <br /> ,.� <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f <br /> Other /_7 `Y � <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 44 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal k <br /> Other Rotary Type of Grout V+ <br /> Other Other Information <br /> _tz. <br /> PUMP INSTALLATION.- Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENTS / / State Work Done <br /> PUMP - -= -� <br /> / / "�State'Work .Done ` <br /> r <br />' ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ► ii <br /> J <br /> iI eby ag to comply with all laws egulati of the n Joaqu Local Health atri t M <br /> a d t S to o Ca fo is ert ming o or egul tin well on tru io Wi FI EE YS <br /> after c le tion my w on a ell, I 1 furnis a San oaqui cal H th Di rict a j <br /> W RILLERS REPORT of the well and notify them before putting the well in use. he above <br /> reformation is tru to t e st o my now a ge an e <br /> SIGNED TITLE G&-rMr4tJ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I fid® <br /> APPLICATION ACCEPTED BY DATE l A 7f <br /> P ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. i <br /> E H 1426 7/72 1M <br />