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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z1-/�Gf� <br /> THIS �PERMIT EXPIRES l YEAR' FROM DATE ISSUED Date Issued <br /> - ,..(Complete In Triplicate) .+ m <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 `Joaqui <br /> County Ordinance". No. 1$62 =and the,.Rules and Regulations of the San Joaquin`Zaca1 'Health District. <br /> f JOB ADDRESS/LOCATION ��� 5'. ���..�Ute-`Tl�tl' YZ4ir 1y �'c�u.� CENSUS'TRACT <br /> Owner's Name Phone .., <br /> Address �.,_ " ow" " �Y <br /> p moi.[. City <br /> Contractor's Name C,, !?ot2 -,j�nC_ License # Phone <br /> TYPE OF WORK (Check) : = NEW WELL /-7 DEEPEN /7—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other � �" <br /> S. <br /> DISTANCE TO NEAREST: SEPTIC TANK C SEWER LINES �G 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 /> --x� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r- <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Alv z_k. y S <br /> Type of Pump a H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> . .pESTRUCTION OF "WELL: �We1l-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 .54fe-3 LZ+L <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 II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION.PRIOR .TO GROUTING AND FINAL. INSPECTION. <br /> E H "1426 <br /> 7/72 1M G�� <br />