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SAN JOAQUIN LOCAL HEALTH 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 y3-2(,2_0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 a - 73 <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. C <br /> JOB ADDRESS/LOCATION f Sa me CENSUS TRACT <br /> Owner's Name W. K.' Lowes Phone 835 -4582 <br /> Address 29563 Bird Rd. i <br /> City Tracy, ,Cal <br />.Contractor Is_Name -He_rinznd&�=$1'os-. -DrllnE Co.a-� -Inc: -,.� ~`Liceinse—li-1163-22—Phone 5225643 <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP-REPLACEMENT <br /> Other / / <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 i <br /> Industrial j Cable Tool Dia. of Well Excavation <br /> x .-lr <br /> Domestic./private Drilled Dia. of Well Casicig y� <br /> Domestic/public # Driven Gauge ,of Casing y. l2 a <br /> Irrigation-. ' Gravel Pack., -Depth-of-Grout-Seal <br /> Other F � Rotary Type of Grout <br /> Other Other Information S%194 -_ oa,,ye r <br /> "1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �+ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done < <br /> ON OF WELL: Well Diameter t. <br /> 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 d <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'. r <br /> TITLE <br /> " <br /> (DRAW PLOT,.PLAN ON F.REVE)kSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT..'USE ONLY <br /> � .. <br /> APPLICATION ACCEPTED BY ATE 'h -�3 <br /> ADDITIONAL COMMENTS: `'°`---�-- <br /> PHASE II GROUT INSPECTION P S I F AL. INSPECTION <br /> INSPECTION BY DATE INSPECT BY ATE CALL FOR FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> y E H 1426 i 7/72 1M <br />