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Y <br /> /P_ S, JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: �� 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466-r6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9.2-LGd24 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedg�T� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin.Lo6al 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 ADDRESS/LOCATION 2044 S. Airport Way CENSUS TRACT <br /> Owner's Name Martin Cerri p[tJ ow/u C iTJ_- Phone 462 0472 <br /> Address 2044 S. Airport, Way City Stockton <br /> Contractor's Name J. A. -�halhamer Co. License # 272 303 Phone 477 1858 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> P TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> 0 Ifff hebiol—ve--Pu—mp--f—ro—m—w—err-mTi-y--I <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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ro <br /> 0 <br /> All structures removed from the property {- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> DESTRUCTION 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 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 �t,� L^ _ TITLE?- • <br /> (DRAW PLOT PLAN ON REVERSE SID-ET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7-z ..._ <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY D� TE <br /> GALL FOR A GR UT INSPECTION RIO 0 GRO TI G AND FINAL INSPECTION. ?7 lz�7z w <br /> E H 1426 Z�.2y/7ZCc� `` �C cnI z/lX7/72 1�M ��I . <br />