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FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1001 E. Hazelton::Ave, i ,: <br /> Stockton, Calif:. <br /> Telephone:. (209) 4666781 <br /> PLICATION FOR WELL CONSTRUCTION-.OR PUMP PERMIT Permit No. 3 <br /> THIS PERMIT.<EXPIRES .1, I'EAIt i R� � :'DATEY5 63 <br /> " ISSUED Date Issued <br /> L <br /> 1 Application is' :hereb; .~mader-.to the :Sari ,Joaq in Lo a Health, District• for a ermi <br /> and/or install the wo-k herein described. This .a P t 'to construct, <br /> I County lOrdinance �No ,f1 62 sand' PPlication is made .in compliance with San Joaquin <br /> theT Rule`s and Regulations of the .Sari•Joaquin -Local!,Health District. <br /> JOB ADDRESS/LOCATION 1 0 <br /> re.r d: CENSUS-TRACT . , <br /> i Owner .,s :Name r .: g� x s� �,, Ts. w . <br /> - <br /> Address SPhone /�(�/ •t /7� 7 <br /> -.- ity . <br /> Contractor��sNe <br /> License # 1 il Phone <br /> TYPE OF WORK (Check) : " AL <br /> NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTLATION PUMP REPAIR /_7Other // FtJTp REPLACEMENT /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> N SEWER LINES r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD iCESSPOOL/SEEPAGE PTT <br /> ! ---.�..� OTHER <br /> INTENDED USE TYPE OF WELL ^ <br /> Industrial w CONSTRUCTION SPECIFIGATIONS <br /> � Cable Tool Dia, of Well Excavation , <br /> Domestic/private Drilled ' <br /> Domestic/public X �. Dia. of Well Casing <br /> Irrigation — Driven 'Gauge of-Casing <br /> * <br /> Other _ Gravel Pack Depth ,of Grout Seal !o oW <br /> Ro.tar ,�y .4` <br /> -�_ Y''` ' �- Type-'of Grout <br /> Ocher Other-Information <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump: <br /> _ `..�' -• � ,.. A.P. <br /> PUMP REPLACEMENT: rt �, <br /> / / State Work Done <br /> r <br /> PUMP REPAIR: State Work bone <br /> r �# <br /> ESTRITGTION OF WELL: Well Diameter` <br /> Describe Mafer:kal and Procedure^; —. Approximate Depth <br /> I hereby agree to comply with all laws and regulations,' oil the San Joaquin Local Health Distri <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 /> dELL. DRILLERS REPORT of the well and notify them b4fore' Putting <br /> Lnformation is true to the best of my knowledge and belief;—_ t well in use. The above <br /> N. <br />;IGNED._ _. <br /> 4 t TITLE INTi;�,as ,n " <br /> (DRAW PLOT PLAN ON REVERSE SIDE) "' � ---�-�-- <br />'MASE I FOR DEPARTMENT USE ONLY <br /> 1'PLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> NSPECTION BY DATE <br /> INSPECTION BY N DATE __,;J6 . <br /> CALL FOR A GROUT ,INSPECTION_PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M f, <br />