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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR•PUMP PERMIT Permit No. S p Yv <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE 'ISSUED Date Issued ( ?� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San{Joaquin Local Health District. <br /> JOB ADDRESSAOCATION 2S_5_aV ILL F-'�C�`3 _ CENSUS TRACT <br /> Owner's Name /���/r?Dit,I� �f�JFF�i� _-- _ _ phone' <br />' Cit t°" SCf}LD� <br /> Address � ��G 8 Fi4� y. <br /> `. tot's Name f I. canse Ph:vne <br /> Contras <br /> k <br /> TYPE OF WORK (Check): NEW WELL /� DEEPENm/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMPAL <br /> INSTLATION / J PUMP REPAIR J / PUMP REPL=ACEMENT /-7 <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Jad ;F- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE OTHER 4.4 <br /> 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 Se 1 . <br /> ,Otherotary Type of Groutft� <br /> Other Other Information P <br /> PUMP INSTALLATION: Contractor <br /> } <br /> f ; Type of Pump H.P. <br /> �, <br /> PUMP REPLACE�MNT: / / State Work Done <br /> PUMP `tEPAIRm- / / - State Work Done w 7- 73 p - .� J �N --TUZi <br /> •- <br /> ! DFmTRUCTION OF WELL: Well Diameter,,. " ` -Appro xmate 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 neer well, 1 will furnish the San Joaqui:nm`Local'He•alth District a <br /> 3 WELL DRILLERS REPORT of mthe well a d notify them before putting the well in use. The above <br /> information is'.true the b of m knowledg e ie <br /> t ;. <br /> _ w w <br /> SIGNED � TITLE __ ,(} c -7�/ =�Z� • <br /> LOT PLAN ON REVERSE SIDE) <br /> # FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY ' DATE <br /> l ADDITIONAL. COMIE'NTS: <br /> PHAS I GROUT INSPECTION p)NW-1Ij#1XAAL INSPECTION' <br /> INSPECTION BY �� DATE Te.-,0,1G•9;� INS DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT .ON " �l <br /> E H 1426 ' e - f 5/731M <br />