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w SAN JOAQUIN LOCAL HEALTH DIS ^T <br /> lOR OFFI, USES 1601 E. Haselton Ave.. Stockton,~4.' lif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NO. 3yskJ <br /> THIS PERMIT EIl'IRES 1 YEAR FROM DATE ISSUED Date Issued ga.2-A_�.s <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 Joaqui <br /> County Ordinance No. 1562 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Joe ADDRass/LoCATION ?3.�. .1;,.,�..�.-" ., <br /> CENSUS TRACT <br /> Owner's nowwAirems �— <br /> ._ Phone <br /> Address __ h O &4K S12 <br /> City _SSpC/rTOIY <br /> Contractor's Name CLAA.P {AI C,,(� G License / 7G� Phone 4/6Z-44 P4? <br /> TYPE OT WORK (Check): M WELL LV DEEPEN /7 RECONDITION /-7 DESTRUCTION /"7 <br /> PUMP INSTALLATION 1-7 PUMP REPAIR /-7—pump REPLACEMENT' /7 <br /> Other �j <br /> DISTMiCE TO NEAREST: SRPT IC TAMC SEWER LINES PIT PRIVY <br /> $ SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE PIT <br /> OTHER _ <br /> INTENDED USE TYPE OF WELL CONSTRCTI <br /> ON SPECIFICATION� Cable Tool Diu. of Well Excavation Domestic/private Drilled <br /> Domestic/public �— Driven Dia. of Well Casing `t <br /> Gauge of Casing j V <br /> Irrigation Gravel Pack <br /> Other Depth of Grout Seal ,� p <br /> Rotary Type of Grout H y <br /> Other Other`I,lnformation <br /> C! <br /> PUMP INSTALLATION: Contractor <br /> Type of <br /> ii.P. <br /> "� REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 State Work Done <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 Healt� District <br /> and the State of Califora!a pertaining to or regulating well construction. Within FIFTELN 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 /> informatio is true to the best of my knowledge and belief. <br /> SIGNED / TITLE , <br /> (D LAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I n FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY /V . DATE <br /> ADDITIONAL COMMENTS: "'---"'���'-� -- <br /> PHASE II GROUT INSP ION PHASE III FINAL INSPECTION <br /> INSPC.CTION PY DATE // INSPECTION BY �� ,e DATE �- f <br /> CALL bOR A GROUT INSPECTION OC P R TO RO INCA/AND FINAL INSPECTfON. <br /> E H 1426 7/72 1M A <br />