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yyy SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FWOFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: "(209) 4666781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g 7 <br /> THIS PERMIT: EXPIRES 1 YEAR FROM DATE- ISSUED Date issued <br /> l (Complete -in Triplicate) <br /> Application is hkeby made 'to the San Joaquin Local Health Districtfor. <br /> p <br /> a 'ermit^to 'construct <br />} and/or install the work herein described. This application is ma�. ,de in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules anis Regulations of the San '3oaquin. L66a1'4e41th District -' <br /> k., Y <br /> JOB ADDRESS/LOCATION i �_S'r /zc,5-4 CENSUS-TRACT r y <br /> Owner's NamePU a- '- . .�� Phone '16t/ <br />{ <br /> Address I- / f <br /> r D 7o�•t City _ -lac4-' 0kr .... <br /> k <br /> k Contractor's Name License AIZORZ9 Phones(( <br /> 4 r <br /> TYPE OF WORK (Check): NEW WELL /�/ /% ..DEEPEN /_7 RECONDITION /7 DESTRUCTION /-7 <br /> r PUMP INSTAL TION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES -^ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PITT OTHER <br /> r <br /> INTENDED� USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V� <br /> Industrial Cable Tool Dia. of Well Excavation " 1A <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing ___ �� t <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ; Rotary Type of Grout <br /> Other Other Information <br /> r; <br /> i' PUMP INSTALLATION: Contractor ,: . - C. _ cnn {� <br /> mp <br /> Type of Pu yl <br /> �./ H.?. <br /> / <br /> PUMP REPLACEMENT: ? <br /> /�/ State Work Done <br /> .PUMP-REPAIR::. -;_/:-/-,State.. _ Work Done <br /> ESTRU : Well Diameter CTION OF WELLF <br /> ---- � � 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 w..' 11".. 1 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 is true to the best of my knowledge and belief. t <br /> j SIGNED TITLE r <br />' PLOT PLAN ON -REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> EAPPLICATION ACCEPTED B / k DATE <br /> ADDITIONAL COMMENTS., <br /> PHASE II T ION " PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE'S " " INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO.GROUTING AND FINAL- INSPECTION. <br /> E H 1426 7/72 IM <br />