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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 7��_�S-y� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. __ —. <br /> Dare I sur.cl c/ <br /> --� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> ^• � �lyCaLic� � is Hereby ka'e to the San Joaquin. Local Health District for a permit to coa -t ; u :t <br /> ,,ujor insz-all the work herein described. This application is made in compliance with Sart Joaquin <br /> County Ordinance 'Nc. 1862 and the Rules and Regulations of the San Joaquin bocal. Hezlath District. <br /> CENSUS TRACT _ <br /> .SOB ADDRESS/LOCATION _ � .:lure <br /> Owner's Name J I I',1 v aih,:er Phone '+77 1`?L,3 <br /> z � res City SUoc'.,7*on <br /> Address 7�j'.. <br /> L n <br /> Contractor's k=z<.D,e nkzA "U License # 200 794 Phone466 0696 <br /> TY?E OF WORK (Check) : NEW WELL / / DELPEN / / RECONDITION DESTRUCTION DESTRUCTION /-7 <br /> 13Li iP jZ S TALLAT ION / / PUMP REPAIR / / PUMT <br /> P REPLACEMENT <br /> 101:h -a / <br /> DISTANCE TO NEAREST: S'P.L C i1j:vit 7� �t. SEWER LINES PIT PRIVY <br /> SLWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> D LSE OF WELL CONSTRUCTION SPECIFICATIONS <br /> InuuS':ria1 Cable Tool Dia, of Well Excavation <br /> i)cmestic/private Drilled Dia. of Well Casing �•] <br /> D Gi.L5,i.0/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> OtherRotary Type of Grout <br /> -`"- _ — --- Other Other Information <br /> 1NSTA11LATION: Contr .ctor Y'k. �. FVQ�C'K ir.o. <br /> --- Type of Pump H.P. 2 <br /> State Work Done Pull ;ei c, ,p a � ; �lI a ;a xsible <br /> "UAP UPAIR: / / State Work Done <br /> DFI�TRUCTION OF WELL: Weli Diameter Approximate Depth <br /> _- -- - Describe Material and Procedure <br /> s: ere�y abr,_ � to ceimply with all laws and regulations of the San Joaquin Local Health District <br /> and tz.e Stale of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ter cal.3l`tion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> LL D 1L LRS Rial'�?RT of the well and notify them before putting the well in use. The above <br /> LaLior;aati.oa is true to the best of my knowledge and belief. <br /> iGNi;D `_ �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI E <br /> FOR DEPARTMENT USE ONLY <br /> T i0 ACC7?TE'D BY DATE /G, <br /> ADDITIONAL COi'-,EN` S: __ � <br /> 1 i�F1S E II GROUT INS; 3�' iON PHASE III/FINAL INSPECT <br /> DATE <br /> INSPECTION BY i r�- (,l_. <br /> INSPECTIONTY E <br /> CA1.1 1JR A GROUT INSPECTION PRTC t .TO GROUTING AND FINAL INSPECTION. <br /> - •; '- <br /> 5/731M <br />