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JOAQUIN LOCAL I-W1,AL1'H DISTRICT " -' <br /> FOR OFFICE USE: / I60 ;, Hazelton Ave. , Stockton, Cal <br /> Telephone (209) 466-6781 <br /> APPLICA <br /> TION FOR WELL CONSTRUCTION OR PUMP PERIMTT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FIROM DE^`:CE ISSUED Date Issued:. <br /> l $ (Complete In Triplicate) r <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.Regula tions of, the San Joaquin Local Health± District. <br /> JOBADDRESS/LOCATIONLi-A <br /> 0 E. ?iw 26 CENSUS TRACT:, <br /> Owner's ;Name Karl. Grupe: Phone.' <br /> h -- _ Phone.' <br /> Address X04, E, , I <br /> Hv� 26 .:Tznden � c.a sf. .City <br /> Contractor's,Name Furviance Dri?1er.s, P.O,Box 61Linden License # a?Y6 jo7 -Phone '/ �_ ( [ `i <br /> 95236 --. <br /> TYPE OF WORKt,(Check) :. NEW''WELL /7C/ DEEPEN / / RECONDITION /7 ,DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / '/ PUMP REPLACEMENT /7 <br /> Other <br /> . I <br /> DISTANCE TONEAREST: SEPTIC TANK SEWER_ LINES PIT PRIVY I <br /> ' SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well .Excavation/ 14" <br /> Domestic/private Drilled Dia.'' of Well Casing 1411 a <br /> a Domestic/public. Driven Gauge of Casing 10 -� <br /> X : Irrigation Gravel Pack . Depth of Grout Seal <br /> Other Rotary Type of Grout 4 <br /> Other Other Information <br /> - } <br /> PUMP' INSTALLATION: Contractor r <br /> Type of Pump H.P. }� <br /> PUMP,REPLACEMENT: / /. State Work Done <br /> PUMP REPAIR: /% State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> i Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations .of the San Joaquin Local Health District" .Y <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 /> WELL4DRILLERS .REPORT of the-'well and notify 'them before putting the well in. use. The above <br /> information is tru the best of Amy knowledge and belief.` <br /> t <br /> SIGNED� TITLE <br /> (DRAW PLOT PLAN ON :REVERSE SIDE) <br /> $ FOR <br /> PHASE T ARTMENT USE ONLY <br /> ; <br /> APPLICATION ACCEPTED BY Or ItI. DATE <br /> ADDITIONALICOMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III/ NAL INSPECT ON,' <br /> INSPECTION !BY., DATE INSPECTION,..BY DATE <br /> CALL FOR A`,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E'H 1426 4/72;. IM <br />