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SAN JOAQ1jIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton"Ave.' .,iStockton, Calif. <br /> Telephone: (209)'1;4W-6781 <br /> -7 <br /> PLICATION FOR WELL CONSTRUCTIOXAOR PUMP PERMIT Permit No. 72-- 6 <br /> THIS PERMIT EXPIRES,­1 1-YEARdFROM�-',DATE)ISSUED `­Ddt4��LIdgu6d 7Y` <br /> (Comp ret6 <br /> j;"j <br /> Applicati otbisDh&reby7,made-itoi theoSan1JoaquinLoi-al llealth DistriCt f bv-a-,peiihit­to -constrfic <br /> and/or install the work herein described. Thi sr_appli cation o is Libmade lin,-,comp r�iance-with- San,--Joaquin <br /> County�sOrdinanceQNo--;31862matid%thd�-,Rus es},andi�;Regulations--;6f dthe,Safi_-J oaquin;-Local,Health `Dis tr-ict <br /> JOB ADDRESS/L �b CENSUS TRACT Z­ <br /> 9 a o I(- "".ri 1' 1 <br /> o �jz <br /> .Owner!Sr' l,)Name0 ,C� <br /> AddresO,2Ao <br /> --------- <br /> Contractor's Name f Z ALk3. a 4 License # 7.3 Phone ,'- <br /> TYPE -OF. WORK.,E(Check) : < NEW WELL.../ DEEPEN RECONDITION j DESTRUCTION / 7 <br /> . : PUMP INSTALLATION PUMP REPAIR ZAI PUMP REPLACEMENT /_7 <br /> Other: <br /> DISTANCE TO NEAREST: 'SEPTIC TANK ­ SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> tn <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 <br /> Irrigation. .Gravel Pack Depth, of Grout Seal <br /> Othdr Rotary Type of Grout <br /> other Other Irif.6rmation <br /> PUMP INSTALLATION: Cdntrzlctor <br /> Type of Pump H.P. A <br /> PUMP r REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done idepod,4 ,: <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 tfi <br /> WELL .DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> infdIrmation is true; to the best .of my knowledge 'and belief. <br /> 'o <br /> SIGNED fs L TITLEPJ- <br /> gm L, <br /> - <br /> (DRAW PLOT PLAN ONiREVERSE SIDE <br /> FOR DEPARTMENT--USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE FI1gALjZXSPECTION <br /> PggE �I GROUT INSPECTION. <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> a . <br /> A <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION't- <br /> 4/72 1M <br /> H 4�� <br />