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f' Ca SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE E: 1601 E. Hazelton .Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Permit leo. 0233 <br />} <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued S=1• y�7� <br /> (Complete In Triplicate) <br /> I Application is hereby shade to the San .Joaquin Local Health District for a permit to construct <br /> C and/or install the work herein described. ' This application is made in compliance with San Jpaqui.n <br />` County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Disprict. , <br /> � '"' . <br /> JOB ADDRESS/LOGATI N Hasosi )?0L4c:� 4r,�, �Ojer1_+!xc-k: CENSUS TRACT ' <br /> t <br /> Owner's Name /i * •, Phone 61v -3'47F6 <br /> r <br /> Address 9 9 C�12�..�-/e.- kA"-6.4 c4-4,r Cm 1c r _ City SS 60ti <br /> Contractor's Name l i,.- _ License # Phone .N?7 /�5 ► <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION _Y/ REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other W ago," r + i <br /> DISTANCE TO NEAREST: SEPTIC TANK _24j2� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> R INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ^� Domestic/private Drilled Dia. of Well Casing f` <br /> ^ Domestic/public �_ Driven Gauge of Casing h <br /> Irrigation Gravel Pack Depth of Grout Seal , a: <br /> Other Rotary Type of Grout <br /> r - <br /> Other Other Information �_�,...-. <br /> PU'cT' INSTALLATION: <br /> Contractor C— <br /> l Type of Pump 4 H.P. <br /> PUMP REPLACEMENT: State Work Doner u 4 'rft <br /> _ �•wr•s a fuF (.a+C//c� !p rixr.eT i+spa Zde, u o- <br /> Pip 'tEPAIR: 'J / State Work Done <br /> X-RR RUCTION 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 /> SIGNED TITLE &Ie—a stn <br /> (DRAW PLOT PLAN ON REVERSE SIDE) d <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTN <br /> INSPECTION BY DATE INSPECTION BYDATE// �?' <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND- FINAL INSPECTION. � � <br /> F x 1426 -5/731M <br />