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` SAN J�IN LOCAL HEALTH DISTRICT <br /> t� US'r` J/ 1601 E, azelton Ave. , Stockton, Calif. <br /> *40 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued p_ <br /> (Complete In Triplicate) <br /> li ition is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /o7 install the work herein described. ' This application is made in compliance with San Joaquin <br /> :t,, Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> AMRESS/LOCATION 2:'j j $s N ���Y CENSUS TRACT <br /> 'n ; Name J&J2 4"t a/ 5,,- Uq 4f4e. Phone 3 '2-g j( 26. � <br /> esa _ _ 'l�3l ST.//,y l�1/,fV city <br /> WOUDS WELL DRILLING <br /> :r�_tor's Name License # ,I hone <br /> _70-2407 ----745-3247 <br /> Ir <br /> it / . <br /> E WORK (Check) : NEW WELL r DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> LAr.CE 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 /> T Domestic/private Drilled Dia. of Well Casing $ Vd <br /> )omestic/public Driven Gauge of Casing /� <br /> `'Irrigation Gravel Pack Depth of Grout Seal 5Z7 ' <br /> `C <br /> Other Rotary Type of Grout <n y� d P e'mre� <br /> Other Other Information f <br />' VSTALLATION: Contractor 9�yjf,yrWA'r <br /> Type of Pump /I H.P. <br />' " PLACEMENT: / / State Work Done <br />' ".LPAIR: / / State Work Done <br />�H -TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />.r )y agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> t.2 State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />:r completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> »i(ILLERS REPORT of the well and notify them before putting the well in use. The above <br />)r anon is true to nthe best of my knowledge and belief. y}. <br /> J]iD _.+�y ..L:C��LL 1Y��/1'ff•!_1L3� TITLE <br /> Ig- (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t: I <br />.I (TION ACCEPTED BY Gam!• DATE 107 7Y <br /> LT,DNAL CONDE.NTS: _ <br /> PHASE 11-GROUT INSPECTION PHASE III/FINAL INSPECTION <br />?F-TION BY lt4DATE /l7 e2/ INSPECTION BY DATE <br />:A-L FOX A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> II 1426 5/731M <br />