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SAN JOAQUIN LOCAL HEALTH DISTRICT a "` <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466--6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ctfl <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE U N�e Issued ,? <br /> ►23 6 c,7 (14 r7-(- (Complete In Triplicate) o <br /> O? <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 /> �p Smf17// <br /> 0,- 5¢r5Vr�irr7`` <br /> JOB ADDRESS/LOCATION <br /> .0 p ��riC�y9 a Ow v,Q„0,V1 ' CENSUS TRACT S-117 <br /> Owner's Name /C� <br /> 3 (.1,�'(, �'%` E,S'�/�.Drg � Phone >3 9 <br /> Address _ /7,2Z _ LSZ2-1Cr1 p.DCity yay , CA <br /> Contractor's Name License # //'7 Phone 36,-JK-.?343' <br /> I TYPE OF WORK (Check) : NEW WELL DEEPEN'/ / RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 <br /> Industrial �—,Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ] <br /> Domestic/public Driven Gauge of Casing A2 C&t1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> e PUMP INSTALLATION: Contractor - <br /> -.—Type of_P-ump_,,_--- - `*4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t PUMP REPAIR: wState Work .Done <br /> k ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyYwith`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 /> r WELL DRILLERS REPORT of the well and notify them0before putting the*well in use. The above <br /> information is a to the best of my knowledge!'`and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT P-LAN ON REVERSE SIDE)• , <br /> j FOR DEPARTMENT USE ONLY <br /> { PHASE I <br /> APPLICATION ACCEPTED BY 4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT.__INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY —DATE' INSPECTION BY - DATE - --2- <br /> CALL <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> a <br /> E H 1426 4/72 1M <br /> F <br />