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n ^ SAN JOAQUIN LOCAL HEALTH DISTRIG, <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. 37 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED . Date Issued 3->d -73 <br /> I (Complete In Triplicate) ©p '�– 07 a —o/ ? <br /> Application is hereby made 4 the San Joaquin Local.Iiealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin j <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> /✓ <br /> c(5 ?s4 £-.As"u� f — _ cENsus TRACT <br /> 'JOB ADDRESS/LOcAT�ON h7lmYlLf' F! P t O <br /> l Phone ^Z o <br /> Owner's Name <br /> Address 7/' ' � City <br /> Contractor's Name License d/� Phone t <br /> Z^ <br /> TYPE OF WORK (Check): NEW WELL /_T. DEEPEN '/? RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / /—PUMP PLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK S R LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .� CESSPOOL/ EEPAGE/�pIT � /OTHER �•5--� <br /> d'/6.CIl4f L'�.t.B.I �SC+i-ii .0/sr t�•- /5S."C <br /> : o ..sic -ci-el •P��..�7•� <br /> SNTENDED USE PE OF( ALL —T.� CONSTRU _ ION SPECIFICATIONS <br /> ' Cable To <br /> Dia. of Well Excavation <br /> Industrial <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor '�'c "" <br /> Type of Pump ' ' • _ H.P. <br /> PUMP REPLACEMENT: JZ7 State Work Done �T)rcY 1)1-2 <br /> /airy <br /> �• <br /> PUMP REPAIR: /7 State Work Done ' <br /> . •l`ESTRUCTION 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 i true to the )be t of my knowledge and belief. <br /> SIGNED TITLE d2,41V <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { / /J DATE <br /> APPLICATION ACCEPTED BY !!{ <br /> ADDITIONAL COMMENTS: PHASE II FINAL INSPE TION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY :1 DATE INSPECTION BY ':'•� DATE <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING FINAL INSPECTION J 4/72 1M Yid. <br /> E H 1426 <br />