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. 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466--67$1 " v ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1.2-da"?3 e <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 Joaquinj <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> _ — 14, , AgCr <br /> .SOB ADDRESS/LOCATIO�T��1'���T►7 JLIIor—J?�✓��ZGj����L�/�, f hf -Jrt-ct-7eTRACT <br /> Owner's Name Cry R L Phone --,Y.1-3 " <br /> 'Address -IR4. etv k 3 6 6 City - A�,y7-Z<- .a <br /> G <br /> Contractor's Name 4kV-. 1j V6,5 Flq4S s P>q111 Jam¢Geo , / L i cense # 'L Phone E.:22— <br /> TYPE OF WORK (Check) : NEW WELL -f DEEPEN/_/ RECONDITION /—/ DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK j 6 ISEWER LINES PIT PRIVY Q I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ° <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation :z <br /> Domestic/private Drilled Dia. of Well Casing /' Zb <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5d� <br /> Other _ Rotary Type of Grout <br /> Other Other Information 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. : <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DF--TRUCTION 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 i <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a j <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 /> SIGNEDG� ��-�-V' _vl �_ak-4 c�z TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />' FOR DEPARTMENT USE ONLY. <br /> PHASE I / 7-- Z o - 73 <br /> APPLICATION ACCEPTED BY DATE <br /> COMNT2-? ' 7 Zo <br /> ADDITIONALMES' <br /> ' .� /�/ <br /> PHA5E II GROUT INSPECTION ' PRAS I I F NAL INSPECTION <br /> INSPECTION BY Z BATE 9/ INSPECTION BY DATE <br /> $« CA,rV-F0R6A��GROUT,SNS EGTION-PRIOR--TO GROUTING AND .F-INAL INSPECTION. <br /> . �. <br /> -E H 1426 - 5/731M 731M <br />