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r <br /> r <br /> ' AN JOAQUIN LOCAL HEALTH DISTRICT <br /> ".-OR OFFICE USE: 1 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 y� <br /> P ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �5 'f51 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 Regulations of the San Joaquin Local Health District. <br /> • n <br /> JOB ADDRESS/LOCATION � `� /� ��Q CENSUS TRACT <br /> Owner's Name Phone26 9� 02 <br /> Address off- J,�I ` d�/' /TSI" c City /Tt /'+ G? <br /> Contractor's Names/ f License Phone, '-_:i ? 42 <br /> TYPE OF WORK. (Check) : NEW WELL /% DEEPEN RECONDITION _, DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION _PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other l I 7TC-/���f_ 7d_ c,—/ �y Lr1 � - /x-/1/.1,) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER }� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial L_ ---Cable-Too l-- Dia. of Well Excavation 106 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ;/_ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor SA)' 'o AVIV . <br /> Type of Pump /_�' Qi ' H.P. / <br /> PUMP REPLACEMENT: / / State Mork Done <br /> PUMP REPAIR: _AC�5tate Work. DoneL. <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 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 belief. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE i JGROUT INSPECTION PHASE IIi F INS ECTi N <br /> INSPECTION BY DATE INSPECTION BY . ATE z. <br /> CALL FOR A GROU INS ION PRIOR TO GROUTING AND FINAL INSPECTION77/71141 <br /> E H 1426 7/72 IM C <br />