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i"AWkN LOCA H�ALTH DISTRICT <br /> FOR OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,2•- / <br /> THIS PERMIT EXPIRES 1 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 andhe Rules and Regulations of the San J9.Aquin Local Health District. . <br /> 14`2r o <br /> JOB ADDRESS/LOCATION d,t.•v ) ��5 �/ CENSUS 4RACT <br /> Owner's Name a- �c„ Phone <br /> Address -74 City L �; _. �ZL16 <br /> Contractor's Name I - License # 14 <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_� RECONDITION /? DESTRUCTION /'7 <br /> AL <br /> PUMP INSTLATION X1PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _N <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 /> 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 <br /> Type of Pump H.P.. . <br /> PUMP REPLACEMENT: / / State Work Done 4-�(L AJW O PZ� cy l� Alle C��oh,.✓a�%o.v S/a o u <br /> PUMP REPAIR* / / State Work Done a olH � e�L. cz�/ C`1 doh ya6cn/ <br /> 7s "4 <br /> ESTRUCTION OF WELL: Well Diameter Ale,,+,, Approximate Depth <br /> Describe Material ana 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED ,. TITLE �,�_„ <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR=DUAgTNENT USE ONLY <br /> APPLICATION ACCEPTED BY 62Gv, DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,,,I);Z/FIUL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO-GROUTING AND FINAL INSPE TIO <br /> 5' <br /> E H 1426 7/72 1M <br />