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�4 y A t 9: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =FOR OFFICE USE: 1601 E. Hazelton Ave <br /> t r; <br /> ., Stockton, Calif. <br /> "gid <br /> Telephone-: (209) 466-6781 - j -3ccJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nb <br /> THIS PERMIT ,EXPIRES 1, YEAR FROM DATE ISSUED zDatie Issuedt ;/ <br /> (Complete '`In Triplicate) ;, <br /> tApplieation is hereby made. to$;the.San Joaquin Local .Health District fora permit toconstruct <br /> install the'work herein described. This, .application is made in compliance with San Joaquin <br /> County Ordinance No. 1,862 and. the Rules and Regulations of- the San Joaquin Local health District. <br /> -JOB ADDRESS/LOCATION S-33 4{/. f3_Y• call"rL` CENSUS.TRACT <br /> a � <br /> Owner's Nameb # <br /> Y .$'ctler C'Lt ccs ss Phone lr3 Q2 3 <br /> V <br /> Address - Li �.. .- City. oc aa. <br />+�Contractor's Name ,1� !�j �. h License #p7 3p3 Phone <br /> FT TYPE•OF-WORK�"(Check): '- <br /> NEW-WELL � DEEPEN / RECONDITION /� DESTRUCTION /� <br /> PLT�3Pa�INST�43 I T (3 7 UMP REPAIR /—/—PUMP REPLACEMENT /-7 <br /> t0ther /�/ <br /> DISTANCE TO NEAREST,. SEPTIC TANK 1S?1Z' SEWER LINES PIT PRIVY �--- <br />� Ft SF WAGE DISPOSAL FIELD v CESSPOOL/SEEPAGE .PLT OTHER <br /> 'F�•INTENDED,.USE ,� ' ±( TYPE- OF WELL CONSTRUCTION SPECIFICATIONS V3 . <br /> Indus'trial_ _ - Cable Tool Dia, of Well Excavation (Q " <br /> Domestic/pr.ivatie Drilled Dia, of Well Casing ze <br /> I �Domestic/public Driven - Gauge of Casing / <br /> Irrigatio'}t " Gravel Pack Depth of Grout Seal . <br />& r Other +� t` !4 Rotary Type of Grout <br /> 4� W <br /> 'Other Other Information <br /> V <br /> SUMP INSTALLATION.+L. Conttkctorayt - - - - <br /> r 10 Type.lof .Pump 22:ZW, H.P. <br /> . �. g <br /> PIMP' REPLACEMENT: / / State Work Done <br /> 'PUMP REPAIR: / / State Work Done <br /> `DESTRUCTION =UF WELL_*: -Well Diameter Approximate <br /> Depth —.-, <br /> � M ,.. Desc.,ribe Material and Procedure <br /> 4�. I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the' State.•of CalifAnia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> raf°ter.'completion of my°'work on a new well, I will furnish the San Joaquin Local Health District a <br /> WE1s ,"DRILL&-S REPORT of the; well and .notify theft before putting the well in use. The above <br /> information is true to, the best of my'knowledge' 'and belief. <br /> S1ED, ; TITLE /P <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> FHAS E I <br /> APPLICATION ACC xF-T,ED Y DATEA ` <br /> �ADDITT AL QMMENTS r <br /> r` PRXry'II" ^ROUT' NSPE TIO HASE II/FINAL INSPECT N <br /> �NSPECTIQi' .,, / A -E / �2d INSPECTION BY DATE <br /> CALLF( INSPECT ON PRIOR TO GROUTING AND FINAL INSPEC <br /> 6, ►: y�'1 7/72 im <br />