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f <br /> �Q SAN JOAQUIN LOCAL HEALTH' DTSTRTCT C <br /> FOR OFFICE USE: 1.601, E. Hazelton Ave, , Stockton, Calif. <br /> Telephone:' (209) 466--6781 <br /> IPI' ICATION FOR WELL CONSTRUCTION OR. PUME PERMIT Permit No. 3 Z <br /> THIS^PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made o the San Joaquin Local Health District for a permit to construct r <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 /> 30B ADDRESS/LOCATION - .fix' yTj <br /> --•c ,G�a� CENSUS TRACT •z4FS-2��r�2` <br /> t <br /> Owner's. Name _ 7® v L iv d - --- - --- - -- - Phone <br /> Address 4! City 1�71 Pa V/ <br /> Qentra•ctor's Name �. }. �/ -� p�,! License # .Phone <br /> TYPE OF WORK (Check) : NEW WELL f-1 DEEPEN '/ / RECONDITION / DESTRUCTION f� <br /> PUMP INSTALLATION/�/ PUMP REPAIR PUMP REPLACEMENT /-7 <br /> i <br /> Other / <br /> DISTANCE TO NEARESTi SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> - I� <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 /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpTevr- H.P. / <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br />. .PUMP REPAIR:. ITT—State Work Done Evil -qb, G AjX C fr Fvc�-lli�,LVC <br /> is <br /> ESTRUCTION 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 FIFTEEI3 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I c�_ <br /> APPLICATION ACCEPTED BY , ATE 7 <br /> ADDITIONAL COMMENTS: ? <br /> PHASE II GROUT INSPECTION P SE III/FINAL SPECTION <br /> INSPECTION BY� DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE <br /> E H 1426 4/72 1M <br />