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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -0F..OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 O I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. 73 _,6t�t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 3 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa uin Local Health District. <br /> .TOB ADDRESS/LOCATION „ - ,. ... ..r_ , ENSU5 TRACT <br /> ... <br /> Owner's Name 2a,�tA 1m-11Phone <br /> Address - --"7 9_7-7 J Gs Cit <br /> Contractor's Maine. iLi License # Phone s . <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN ,/ / RECONDITION /_/ DESTRUCTION J7 <br /> PUMP INSTALLATION =F-= PUMP REPAIR / / PUMP REPLACEMENT /- <br /> t Other / J <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 <br /> If PUMP INSTALLATION.- - Contractor /f ,, - - - <br /> Type of PuinpH.P. <br /> PUMP*#9=922= State Work Done r�-�-�-� s� /�G k"'01-` <br /> PUMP. 'REPAIR: /. J. State Work Done <br /> .PF.GTRUCTION-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 .St"ate 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 /> f WELL DRILLERS, REPORT'of the well and notify thein before 'putting the well in use. . The above <br />€ information is true,..to_ the_best. of. myknowledge an belief. _ <br /> SIGNED A.ITITLEAJ. <br /> t . .... . .. , . . .. D PI. LAN ON <br /> VERSE SIDE) <br />! FOR DEPARTMENT USE ONLY <br /> PAASE I �f <br /> APPLICATIOhT- .ACCEPTED. DATE . Z <br /> ADDITIONAL COAMNTS: <br /> P ... .. . . .:.I ROUT INSPEC OSI PHA I I/ NAL INSPECTION <br /> INSPECTION BY :�"`- .. .• DATE . - INSPECTION BY DATE - <br /> ”-CALL-FOR-A-GROUT_INSP-ECTION.-PRI©R...TO-.GROUTING..AND...FSNAL INSPECTION.s - <br /> E H 1426 ___ - 5/731M <br />