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SAN JOAQUIN LOCAL -HEALTH DISTRICT <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. 23-31-7 P <br /> y y_0 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> b (Complete In Triplicate) AIA) f�7-- cf-7a .-o <br /> Application is her by 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 JoaquiT <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .JOB ADDRESS/LOCATION L <br /> ��� � Q �-� t •� CENSUS TRACT <br /> Owner's Name vAl L4- <br /> Phone . <br /> Address City <br /> Contractor's Name Q y�}per ( _ t y License # Phone 474 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /7 DESTRUCTION /_7AL <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT 1_7Other — <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINKS PIT PRIVY <br /> -�} <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,M INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ��— Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven <br /> Gauge of Casing <br /> s _ Irrigation - Gravel Pack Depth of Grout Seal <br /> (Other Rotary Type of. Grout <br /> Other Other Information <br /> r PUMP INSTALLATION: --Contractor Qjlj <br /> s�4 <br /> Type of Pump <br /> e— <br /> j 7 H.P <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP REPAIR: J2g/ State Work Done -- <br /> ,DESTRUCTION OF -WELL: Well Diameter ` <br /> . •— <br /> Describe Material and Procedure Approximate Depth <br /> ri, hereby agree to complywith all laws and nd regulations of the San Joaquin Local Health District <br /> and the State •of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Iafter 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 ief. <br /> SIGNED <br /> IT LE _r-j <br /> (DRAW PLAN ON RE SE SIDE — . <br /> EPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE/ <br />( ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE II FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE d <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br /> INSPECT ON. <br /> E H 1426 <br /> -, ry 'R t' '� 7/72 1M <br />