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SAN JOAQUIN LOCM, HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif =� <br /> Telephone: (209) 466-6781 <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit' No. 7�7 <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued /C l -7 2i <br /> (Complete In Triplicate) k <br /> Application is hereby, 'de 't 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'Vthe Rules-and Regulations of ;the San Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION �uy� /�l�iR �TXRLf�O /? I7 CENSUS TRACT <br /> Owner's' Name LLG/�/IV 6 Phone <br /> :: �: <br /> Address 1:7116 17 e �A `7,4-R 1- 00 /3 .0 City _ TkN car/F <br /> Contractor's Name a,&/!/� RSA L P"-HI-3 'E S «-/7 P4 Y License # Z S yb/Phone t,.64 g si t <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Ira., SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E <br /> Industrial Cable Tool Dia. of Well Excavation f <br /> Domestic/private Drilled Dia. of Well Casing 1, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth. of Grout. Seal <br /> Other Rotary Type of Grout Q� <br /> Other Other Information p! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. S' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .R STRUCTION 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 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/hand belief. <br /> SIGNED a-," � �Grr �c u*AL 'TITLE - <br /> DRAW nOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE IDATE ' i��ZFj v . <br /> APPLICATION ACCEPTED BY <br /> 1 <br /> ADDITIONAL COMMENTS: INSPECTION <br /> PHASE II GROUT INSPECTION )ot <br /> INSPECTION BY DATE INSPECTION DATE CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 4/72 1M <br />