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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OF-VCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f3-11?� . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> flCom 1e p <br /> Ax�//7. 1 ( P te, In Triplicate) A" ' 0� �- X710--06 <br /> ppl�catian:.is herebymade 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 /> 1 <br /> Jos ADDRESS/LOCATION Al, CENSUS TRACT <br /> Owner's Name ` g ,3o , <br /> Phone .3 <br /> Address A F �.� City �4 <br /> Contractor's Name License #�G�3 7 Phone3L d- <br /> TYPE.OF WORK-(Check) . NEWSWELL '/�.JiDEEPEN `/-7 RECONDITION.-FT—DESTRUCT—ON <br /> POMP INSTALLATION /—/,—PUMP REPAIR PUMP REPLACEMENT /- <br /> Other /-7 - r <br /> DISTANCE TO NEAREST: SEPTIC TANK -- \SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD-,, PIT OTHER <br /> 7r_ . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool x Dia:of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing' � <br /> _ Domestic/public Driven, Gauge' of Casing <br /> _Irrigation Gravel, Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 11.1.eZt,sC;, <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> { <br /> PUMP REPAIR: (' State Work Done <br /> ,DESTRUCTION OF WELL Well Diameter ° Approximate Depth <br /> Describe Material and Procedure 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 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 /> information itrue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F DE NT USEONLY• <br /> PHASE I _ <br /> APPLICATION ACCEPTED B DATE /G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY / DATE /170 <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M �~ <br />