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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466--6781 <br /> APPLICATION FOR WALL CONSTRUCTION OR PUMP PERMIT Permit No. 7,(!-211f 4-11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2 <br /> (Complete In Triplicate) <br /> Appliedtion is hereby made to the San Joaquin Local .Health District for a permit to construct 1 <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 AaDRESSAoRGAR&M CENSUS TRACT <br /> I <br /> Owner's Name i ke h, Phone <br /> Address - "� R <br /> ja 4 ,d City 1Lb <br /> Contracior's Name AkA <br /> it � License #,&� Phone <br /> TYPE OF WORK (Check): NEW WELL / EN DEEP <br /> a / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/ _ <br /> / PUMP REPLACEMENT r7 <br /> i Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 5: SEWER LINES <br /> PIT PRIVY <br /> � SEWAGE DISPO AL FIELD -w— L./SEEPAGE PITS/ '�- <br /> PROPERTY LINE - PRIVATE D(? <br /> ' MESTIC WELL PUBLIC r OME�STICTWELL °""�" <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONfSPECIFICATIONS <br /> Indu ;-trial _ Cable Tool Dia. of Well Excavation - <br /> - ° Domestic/private _ K Drilled Dia, of Well Casing It � . <br /> x Domestic/public Driven Gauge of Casing ; �( <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary — Type .of Grout i <br /> Disposal Other _ _ Other Information i � <br /> Geophysical. Surface Seal Installed Bf : <br /> PUMP INSTALLATION: Contractor <br /> -4& <br /> f TyPe:.,Pf-Pump, E <br /> �.:,• , <br /> =1�e4 404A H.P. <br /> PUMP T <br /> REPLACEMEN : ' <br /> . � �� / / State Work Done <br /> PUMP <br /> IR::REPA " ` `- # <br /> / State Work Done <br /> , <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ---- - <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. I WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL <br /> SIGNED TITLE <br /> MHAV PLOT P ON REVEI2 SIDE <br /> % '� F ` " FOR DEP. TMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY ^� <br /> ADDITIONAL COMMENTS: <br /> DATE S <br /> PHASE II GROUT .INSPECTION PHASE III FINAL INSPECTION <br /> r �� 3 <br /> INSPECTION BY_.- DATE `7 INSPECTION BY DATE 5-- 3- <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />