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- SAN JOAQU.IN LOCAL HEALTH DISTRICT ��" D <br /> FOF. OFFICE USE: -. 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. ,7113 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b 1,30 7 7 <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 Ban Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the Sn Joaquin Local. Health District. <br /> 3l of [ <br /> .TOB ADDRESS/LOCATION 'N/.J C�2,t/,5Q--�Qgld,er,Gs 4,✓o-- iCENSUs TRACT <br /> Owner's Name L 1-4 VD ��i2�1 Al - Phone <br /> i <br /> Address �?�7D C' �QiGG r3 C,/&C City GegD��CRf <br /> i` Contractors Name _ j ,� C�,�GG �.PiGG!/d�� Pf-o2L!/Y� I License # // Phone X68 <br /> TYPE OF WORK (Check): NEW WELL '/ / DEEPEN '/ 1 RECONDITION %/ DESTRUCTION <br />'f PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT ` I <br /> Other 1� Z'N.S'TgZG 1 `� 'A�'i ct� l/�' Pit 6� <br /> DISTANCE TO NEAREST: 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 /> f Domestic/public Driven Gauge of Casing-. <br /> Irrigation Gravel Pack Depth of Grout <br /> ,Seal <br /> Other _ Rotary Type .of Grout <br /> Other Other Information ' <br /> i <br /> PUMP INSTALLATION: Contractor JA L <br /> Type of Pump QiMP _ H.P. /Q <br /> PUMP REPLACEMENT: /X/ State Work 'Done Cg1m7T/xU ESL._ __ -_-----_ -- - - <br /> PUMP `REPAIR: / / State -Work Done <br /> I pFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure n: . <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 <br /> 14ELL 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 ti <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />! FOR DEPARTMENT USE ONLY <br /> PRASE I � <br /> APPLICATION ACCEPTED .BY DATE 6� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY .DATE - . INSPECTION BY DATE 7- � <br /> 'CALL-FOR-A-.GROUT INSPECTION-PRIOR-TO- GROUTING AND FINAL INSPECTION. <br /> z�� <br /> 5/73iM <br />