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Z/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF-FI'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-/ IQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ¢`7� <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .h o.e f'w 5%qe Arad ".CA <br /> JOB ADDRESS/LOCATION re Larc:t� s'/Y�� Q4, X -3'f CENSUS TRACT <br /> Owner's Name 0 ^9_0 Tey Phone t��'- ,7/2- <br /> Address G 7 (,� , /'�k'f«S �'.(�?c+ (, � E� City <�,o D/ <br /> Contractor's Name 5-nn 5a "an CC License # Phone (9 71 <br /> s <br /> 0. <br /> 211 awl C...........3;6 9t <br /> TYPE OF WORK (Check): NEW WELL / D%EPEN /7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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: / Mate Work Done jee "ap/6 rvo_ f�u�c,p (,c�� �� �t,� ®j A-D <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 notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDSan JQcgUiro PUMP CO. <br /> TITLE <br /> (Divisinn of Son oa uin Sul hur Ca <br /> ;jffiRAW PLOT PLAN ON REVERSE SIDE acramento St. <br /> FOR DEPARTMENT USE ONLY lcdl, California 95240 <br /> PHASE I "' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />