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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'OAve:; 'Stockton, Calif. , <br /> Telephone:' (20;) :466-6781 <br /> APPLICATION FOR WELL•'CONSTRUCTION- OR PUMP PERMIT Permit No.7L 1 3 D <br /> 471741 <br /> THIS PERMIT r.EXPiRES:c1frYEAR IFROM DATE ISSUED Date ssued,5 <br /> r " •' (Complete Zri Triplicate) <br /> 'Application. is;herebyrmade<to the:SasrjJoaquinfLocal Health District fora permit 'to construct <br /> and/or install .the work herein described. This.application•is:made`in:compliance with San Joaqu. <br /> County•Ordinance.No:;,1862:aind;,th(i•.Rules`:and..Re'gulations':of .the San Joaquin Local Health District <br /> 'JOB ADDRESS/LOCATION .21'00f7AMPrI/ OF ROTN /+/J CENSUS TRACT' <br /> Owner.'s Name, <br /> t if�rt `)A� j- �ir=fl'�7{��i :L`.�,.r ,i s:, ;,c :,Phone yliL ' .ZD�/ <br /> 'Address .22 /L ) N/1A1,91? City STOcKTrrN u <br /> Contractor's NameW�%rL/L License ll L `J Phone ' -S <br /> 'TYPE OF WORK (Check): NEW",WELL/I DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION/ UMP REPAIR/ / PUMP REPLACEMENT <br /> Other; <br /> ' DISTAN.CE'TO NEAREST: ;SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER G <br /> i <br /> ' NTENDED USE !I TYPE_ 0WELL CONSTRUCTION SPECIFICATIONS- ; <br /> Yndustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public !' Driven` Gauge of Casing 1�tT <br /> 1 Irrigation Gravel.Pack Depth of Grout Seal <br /> Other Rotary Type of Grout r?W&jr <br /> Other .Other Information <br /> f y <br /> PUMP INSTALLATION: Contractor !Q719WINC. <br /> ' Type of Pump V • : H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ' PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use". The above <br /> ! <br /> information <br /> isJtrue <br /> /to�the bes�t of.my knowledge and belief. <br /> 1 SIGI ED ��J(-r✓�u/� /j' ! („(�G�' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY .= +mak DATE <br /> ' ADDITIONAL COMMENTS: '` s <br /> PHASE YY GROUT INSPECTION PHAg nIII/FIN CTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL_ FOR A GROUT,INSPECTION,PRIOR_TO„GROUTING AND FINAL INSPECTION. I <br /> E H-1426 4/72 1M <br />