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1' <br /> ComC <br /> SAN JOAQUIN LOCAL III:ALT's:I 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. 7 1 -_� <br /> f <br /> ✓q � ^k� \THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED >� ate Issued 6-,)[-2 y, <br /> i °U (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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z41© ?fit CENSUS TRACT <br /> Owner's Named N ` f-' 1e�1� ���7 Phone <br /> Address L.tF � u 2(6 , City Q _ <br /> Contractor's Name Jya U License # Phone 7�- - " <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/7 RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY J 5 <br /> SEWAGE DISPO Af' FFIELD. CESSPOOL/SEEPAGE P1rT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS b <br /> Industrial Cable Tool Dia. of Well Excavation /Q <br /> ` Domestic/private Drilled_ Dia. of Well Casing , 1Ar <br /> Domestic/public Driven Gauge of Casing [J <br /> Irrigation Gravel Pack Depth of Grout Seal =fie O <br /> Other _ Rotary Type of Grout �� %f <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump l H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / / 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 new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and otif ' them before putting the well in use. The above <br /> information is a to the bes� of kno edge and belief. <br /> SIGNED <br /> ' L, TITLE Vu <br /> D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Z-A�',� �� INSPECTION BY �' _ DATE _3 -77- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. w' <br /> E H 1426 4/72 1M <br />