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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE t3SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> 7 11 LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT MIRES l YEAR FROM DATE ISSUED . Date Issued 7 i <br /> (Complete In Triplicate) <br /> Application is hereby made to he San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein escribed. 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 /> /6 �"o r ). �,4 <br /> JOB ADDRESS/LOCATION ,�C�,4� T��D //zw, - JL /!j(.L CENSUS TRACT <br /> Owner's Name _—A-MOR7` W®T� R ., .._,.. - Phone <br /> Address _ �l1, A9_ //l/1!r , /�Sf„ll /u LLy ,CJ _ City <br /> Contractor's Name S �¢; X11 ,� (OU WS License # a / Phone <br /> -5 C <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN "/ / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION &7/—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 ...+ <br /> Industrial 1K Cable Tool Dia, of Well Excavation <br /> >( Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 16 O . <br /> Irrigation Gravel Pack Depth of Grout Seal L4 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> a <br /> PUMP INSTALLATION: Contractor S� <br /> Type of Pump ii S'lBirb H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 DRILLRRS 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// 01 TITLE / <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE b' <br /> ADDITIONAL COMMENTS: <br /> —j— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ,� - ,,�' � .�' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />