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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltoni:Ave. , Stockton:, Calif. <br /> Telephone: (209),.1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L g Z Z <br /> THIS PERMIT. EXPIRES 1,YEAR FROM DATE 'ISSUED• Date Issued Z__ <br /> G (Complete" :In Triplicate) <br /> Application is hereby,.made-to the.San.,Joaquiri 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 /> k County Ordinance No. - 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tY,^A Zs� 1�m�E AS 7.y�/�ee /�RD L3 g 7.5,0 ,;r& C ENSUS TRACT <br /> Owner,'s Name Q,* � CA ' Phone ' <br /> Address L I WA013 L& &009City S 7`-t'A/ c 4 t./,C— <br /> Contractor's Name e=d License # Phone '4,4g o _ <br /> , TYPE OF WORK (Check) : NEW WELL/ / DEEPENT/ RECONDITION /_7 DESTRUCTION 1-7 <br /> 'PUMP 'INSTAL-LATION-'/ `/ PUMP REPAIR''%% -PUMP"REPLACEMENT -2 <br /> Other <br /> I DISTANCE TO NEAREST. SEPTIC TANK r/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial. Cable Tool Dia. of Well Excavation <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 Rotary Type of Grout <br /> Other Other Information ' ' <br /> k <br /> .. .PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. J%.- <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 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-t.�- f.. f' �, /� _ TITLE <br /> (I)RAW4PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A — 7 2 <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE le, -7;- <br /> CALL FOR A GROUT INSPECTIONP_RI.OR TO GROUTING AND FINAL INSPECTION. <br /> E H 142.6 ; _ . 4/72 1M'' <br />