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SAN JOAQUIN LOCAL HEALTH DISTRICT - I <br /> T-IOF.••OI' ICE USE: 1601 E. Haxeltoa Ave., Stockton, Calif. { !:- <br /> '-"` Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 77-47-240 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-,2-_2,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin ?Focal 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. 2 and the Rules urns of the San Joaquin Local Health District. <br /> / 2 -� r <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Ot� ZOwner's Name ��� Phone <br /> Address I DI..I /`t.l�gf- L7 1�% ��1 City <br /> Contractor's Namer-4 , & License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other i / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 4INES PIT PRIVY <br /> SEWAGE DISPO AL FIELD ,- CE SPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation zi <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 k Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump / H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,pF�TRUCTION OF WELL: Weil Diameter Approximate Depth <br /> Describe Material and Procedure LEFT I aleol;, ?dv,",00, Z^f AjoE--® <br /> I hereby agree to comply with all laws and regulations of oaquin 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 /> SIGNED e r-P TITLE /`]�1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE— <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY l/i/ DATElO�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PJIAS"I/FIM INSPECTI <br /> INSPECTION BrG?�OUT- INSPECTIPN <br /> DATE S ZS- 7 INSPECTION DATE <br /> CALL FOR - PRIOR TO GRO TING AND FINAL. INSPECTIpNH 1426 � 7 t� S,AT. 5�2 /�S'T' <br />