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c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 .. <br /> FOR OFFICE USE: - 1601 E. HazeltonAve. 'Stockton, Calif. ' <br /> Telephone.::' .."(2b9) 466-6781 <br /> APPLICATION FOR WELL C�ONSTRUCTION' OR PUMP PERMIT Permit No. �L ? <br /> THIS PERMIT. EXPIRES l'YEARsFROM-,,TATE ISSUED- = -Date Issued 3_J7 A"' <br /> Fr.sr..s ��. ('Complete In Triplicate) <br /> Application- is ,hereby imadexto the-�)SanjJoaquintLocal Health Districtrfor. a permit'-to construct <br /> and/or install the work herein described. Th s_applicationiis made^ in:compliance with' San Joaquin ! <br /> County <br /> Ordinance,-No-;,,1862. <br /> No-:•,1862.-and';i theq:•.>F Rul�e's'S`E.)S and;-Regulations, }o- fi.J:.'>rt•.�,her,'San'J <br /> an'Joaquin Local <br /> .l Hea1l— <br /> t <br /> h District <br /> 2 " ] <br /> V� �r�FS CENSUS TRACT <br /> JOB ADDRESS/LOCCX <br /> b" :0 <br /> '33.2 <br /> Owner's:Name k ( . �.' <br /> �vwGvv'�6. ►,� s ` <br /> Address 1 � �--s.. - City. . . . .. , <br /> =w.. .__... . _. _..� J._. .• � 7027 License # d232e Phone <br /> Contractor's Name - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION / / DESTRUCTION /� 1 <br /> ATN V I P-UA AIR I IPUMP REPLACEMENT <br /> PUMP `INSTALLIOI? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK�g" SEWER LINES PIT PRIVY ~~ <br /> E SEWAGE DISPOSAL FIELD D — CESSPOOL/SEEPAGE PIT <br /> 4 <br /> I� INTENDED USE TYPE OF; WELL CONSTRUCTION SPECIFICATI NS <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 / C <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> d <br /> k PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done ` <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 I regulating well construction. Within FIFTEEN DAYS . <br /> l furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, I wil <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true tot best of my kn 1 dge and be ef. <br /> SIGNED ITLE _ <br /> DRAW PLOT AN ON RSE SIDE) <br /> , R DEPARTMENT USE ONLY <br /> f T_M1 �..-.:i.. <br /> PHASE I �A/ DATES 3l Z <br /> APPLICATION ACCEPTED BY 4 � <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE II /FINAL , NSPECTION <br /> INSPECTION BY �+A. DATE - Q�� INSPECTION BY _ �; �7 DATE <br /> *CALL FOR A GROUT,.INSP,ECTION,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 .4./72 1M <br />