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' SAN JOAQUIN LOCAL FEALTH DISTRICT <br /> I�t�R OFFICE USE: -2601 E. <br /> Hazelton Ave. - <br /> , Stockton, Calif. <br /> ` <br /> Telephone: (209) 466-6781 kv <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> x ' <br /> 4 <br /> g THIS PERMIT EXPIRES i YEAFROM DATE-ISSUED , <br /> Date Issued 3 , J� <br /> (Complete In Triplicate) - 4 1 <br /> t Application is hereb� made to the San Joaquin Local Health District four a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin j <br /> f r <br /> County Ordinance No. -1862 and'. the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT S�17 <br /> Owner's Name <br /> Phone <br /> Address ` <br /> city <br /> �J 7 <br /> Contractor's Name / (%_A <br /> c a ffe S License ��f Phone f /LEA <br /> `"!. <br /> TYPE OF WORK,:(Checic):.. ,NEW WELLD <br /> / � - _ <br /> EEPEN /-./y RECONDITION-/ /--DESTRUCTION_/-7 <br /> PUMP INSTALLATION <br /> REPAIR / / PUMP REPLACEMENT— /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> SEWER LINES PIT- PRI <br /> SEWAGE DISPOSAL; F LD CESSPOOL/ PAGE PIT -� <br /> ' � 'r' -z OTHER <br /> INTENDED. ' S E t PE OF WELL <br /> Industrial C NSTRUCTION SP FIC IONS <br /> Cable Too] Dia. of Wej.LExcavation <br /> Domes Ic/pt ' ate Drilled of Well Casing <br /> Dome tic/public Driven <br /> Irrigation Gauge of Casing r k� <br /> Gravel Pack <br /> Other �P'tt Seal I , <br /> -Rotary Type of Grout " / " �; <br /> OtherOt <br /> Information � <br /> 4G` ` �Yuy�,.�a•-- �€f ,per~ �.. <br /> Yf <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUMP REPAIR: / State Work Done <br />,DESTRUCTION OF 'WELL: Well Diameter - - <br /> �i Describ4al <br /> terial d Pro edu Approxibate_Depli --'� - t <br /> I hereby agree to comply withlaws 'and regulations the San Joaquin yLocal Health District <br /> and the State_-of. California pertaining to or regulating well-construction.after completion of my wor'k�'`on a.,new well, I will furnish the San Joaquin LocalhHealth District a <br /> WELLA)RILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true tote best of my knowledge and belief. 1 <br /> SIGNED � � 91 rldza <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE ' <br /> 1 <br /> PHASE II G UT IN E ON' PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATES 6.L� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH1426 - -� <br /> 4/72 1M �, � <br />