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SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> - HAib ".Stockton, Calif. <br /> VOR OFFICE USE: 1601 E. lton��A�re- -1 <br /> "TelePhon&i,'-:.'(209)-,466;6781 <br /> Pump PERMIT Permit No-/2Z2429—.,� <br /> APPLICATION FOR WELL CONSTRUCTION`>OR <br /> PrRMITEXPRES -11,TEAR.,FPOM�DATEt'-ISSUEDI""' <br /> -V Dateilssued <br /> ..THIS <br /> I' T ipli-&-atc) <br /> strictlfor­,apermit to cOnstruci: <br /> Applidatiot,�lib�ho-reby,rmade-!ito� zt,he�-,Sa'a'lJoaquo�-aI He-al�h Di <br /> work herein described., -Thi�uappli Cati0n,�-is�'made in--COMP liaftce- with ,Sari kf Joaquin' <br /> . and/or install the in Local �Health District. <br /> :-th6:,Ruleg`� vions-1 the',-,SafiJoaqu <br /> . County...,Prdinance:,,No.11862,�)avd,. and-�Regula <br /> SUS; TRACT J q <br /> r:)Tdt-,e0q u'-AJO Xr" CEN <br /> JOB ADDRESS/LOCATION 3 oxo <br /> 1 eT11 Phone <br /> • owner <br /> City_ <br /> Address , <br /> Licensees hone 0 0 <br /> Contractor's Name <br /> -7 DESTRUCTION /7 <br /> DEEPEN RECONDITION <br /> _TYPE OF WORK .(Check) : NEW WELL II --PUMP REPAIR /;�PUMP REPLACEMENT -77- <br /> PUMP,INSTALLATION <br /> Olher�,3/7/, <br /> DISTANCE TO NEAREST: SEPTIC TANK' -.,,SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `CESSPOOL/SEEPAGE PIT OTHER. <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE . TYPE OF WELL Dia. of Well Excavation <br /> Industrial Cable Tool Well Casing <br /> 'Domestic/private Drilled Dia. of $) <br /> Driven Gauge of Casing <br /> Domestic/public Depth of. GroutSeal LA <br /> i. Irrigation Gravel Pack Type of Grout <br /> Other Rotary <br /> Oth&r" Other Information <br /> ---------- <br /> -7A <br /> Pump INSTALLATION-: Contractor <br /> .......... �77H.F. <br /> Type ofPu'mp 7 <br /> PUMP REPLACEMENT: State Work,Done <br /> Y­ State Work Done <br /> PUMP REPAIR: <br /> Approximate Depth <br /> WELL-. Well Diameter' <br /> .DESTRUCTION OF Describe Material and Procedure <br /> I n Joaquin Local Health Distr ict; I <br /> I .a. ........... <br /> I hereby agree to comply <br /> s and regulations of the S <br /> and the State of California pertaining to or regulating well' coinstruction. Within FIFTEEN DAYS <br /> well, I will furnish the San Joaqun Local FIFTEEN <br /> a <br /> after completion of my work on anew <br /> WELL DRILLERS REPORT of I 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 /> TITLE <br /> ................... <br /> SIGNED (DRAW PLTO�PL�ANON REVERSE E SI <br /> Dt) <br /> FOR DEPARTMENT USE ONLY <br /> - '- <br /> PHASE <br /> DATE �A- <br /> a 2 2 <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: • PEASE III/FINAL INSPECTION <br /> PHASE II GROUT—'INSPECTION -- ��DATE J�- <br /> INSPECTION BY DATE. 13y <br /> I — INSPECTION <br /> , <br /> CALL FOR A GROUT_INSpEc,TION_?Rlplk,TO. GROUTING AND FINAL INSPECTION. 4/72 1M <br /> i-H 1426 <br />