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SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> SOF. OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3-77 <br /> (Complete In Triplicate) See 1�� Arml/ 76 ZoY- <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 /> a <br /> County Ordinance No. 1862 d the Ru,�s Td Regulations of the San Joaquin Local Health DistTrict, <br /> • ve-'ITrVv-s <br /> JOB ADDRESS/LOCATION 12jjorZrj4 - ' &*Xr CENSUS TRACT <br /> Owner's Name PbGt7R 1�4 }Fj Phone 8Z 3-Z� 3 <br /> Address �9ZszS C� . � .I- - <br /> City MA>411�c A <br /> Contractor's Name (,(,�[� Qt�f ��r� License Phone <br /> z 275 <br /> TYPE OF WORK (Check): NEW WELL IST DEEPEN -/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION Pt,"MP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / --- <br /> DISTANCE TO NEAREST: SEPTIC TANK bD SEWER LINES PIT PRIVY <br /> SEI4AGE DISPOSAL FIELD 7r CESSPOOL/SEEPAGE PIT OTHER p� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS IN <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing o <br /> Domestic/public Driven Gauge of Casing <br /> 2 Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> E <br /> PUMP INSTALLATION: Contractor ZZ K E C t 6. rye L <br /> Type of Pump U H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP 'tEPAIR: State Work Done <br /> ,DFRTRUCTION 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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL <br /> &RS REPORT of the well and notify them before putting the well in use. The above <br /> informati is rue to t e best of my knowledge and belief. <br /> SIGNED TITLE <br /> (D W PLOT PLAN VE <br /> ON RERSE SIDE) <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> / <br /> APPLICATION ACCEPTED BY L DATE <br /> ADDITIONAL CO;DMNTS: <br /> PHASE II GROUT IiSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 - - K/71i,� <br />