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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-jc/Sp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7�23 <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 comp liance"with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> " <br /> JOB ADDRESS/LOCATION. Ahle. I.Cr o CENSUS TRACT <br /> Owner's Namedtkk <br /> I' 1 <br /> Phone it <br /> Address ;R At I else City <br /> Contractor's Name cf 1 AO License # /�� <br /> k�Phif ne <br /> TYPE OF WORK (Check): NEW WELL / I DEEPEN /_/ RECONDITION /_7 DESTRUCTION /�I� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / III ri� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I',, <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS .., <br /> Industrial Cable Tool Dia. of Well Excavation I!I <br /> Domestic/private Drilled Dia. of Well Casing �! <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal I! <br /> Other Rotary Type of Grout II! <br /> Other Other Information III <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump . IVH.P. Y <br /> PUMP REPLACEMENT:' / / State Work Done '?6d,( a/w <br /> i <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I'f <br /> I!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�IFIFTEEN 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 o knowledge-arid belief. <br /> SIGNED <br /> .TITLE II <br /> XbFKW-TiD5Tr`PLAN ON - RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j �a Ili <br /> APPLICATION ACCEPTED BY DATE 3112 17 7j <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION BY `DATE'il <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS 0 <br /> E H 1426 7172 1M � <br />