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�p <br /> � h'j. 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. ,r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)T <br /> Application is hereby m' de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work!lherein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 7862 an he Ru es an Regulations f the San Joaquin Local Health District: <br /> x <br /> JOB ABBHS LOCATION 6de, T r �, CENSUS TRACT <br /> Owner's Name -al Irl I` �c_���O Taj- - Phone <br /> Address JI&7Ire 1 c / City _ <br /> Contractor's Name 13Y 62 ,5 <br /> h TYPE OF WORK (Check) : NEW WELL / DEEPEN / 1 RECONDITION DESTRUCTION /? <br /> PUMP INST TION / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY yt,e <br /> SI�WAGE. DISPO AL-F-I-ELD: ..CE SPOOL-/-SEERAGE-PIT —OTHER-- <br /> INTENDED <br /> OTHER <br /> _ k <br /> INTENDED USE TXP9 OF WELL t ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ..Cable-T-oo-1Dia:-of We11 Excavation - �r2C, <br /> Domestic/private - X,--Drilled ` " D14. of'Well Casing / Vi a � <br /> Domestic/public Driven Gauge of Casing / 2- <br /> Irrigation <br /> 2-Irrigation c : Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type of Grout <br /> IM ! Other �, - -- Other Information <br /> Y <br /> PUMP INSTALLATIONo (Contractor -�-�2 ` � ,Z" � <br /> Type of.FPump H.P. <br /> PUMP REPLACEMENT: / / State Work Done/ <br /> PUMP REPAIR- J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter�-- 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-n-ew-we'll;I will furnish the San Jo`aquin4-Local-alDistrict a <br /> WELL DRILLERS REPORT of:� the well and notify them before putting the well in use. The above <br /> information is tr to the best of my knowledge and belief. <br /> SIGNED I� TITLE <br /> IM (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ``\Wti DATE T �dy la-73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSIACTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY DATE -11.- - <br /> CALL FOR A GRO INSPE ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �. E H 1426 if 7/72 1M (1 <br />