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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued li� Q 7y <br /> (Complete In Triplicate) <br /> Application is hereby made to`Ithe Sari 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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g:�a Q It) CENSUS TRACT <br /> Owner's Name Ea /?-S h L �6 SS a G1 A-T,r-,s - ---- -- Phone �J-- a 3 <br /> Address �- �. SC o7r D pr 6. City - <br /> Contractor's Name L`F H- �ci � License 1114 237-3 Phone3 C <br /> TYPE OF WORK (Check): NEW-WELL / / DEEPEN /? RECONDITION / / -DESTRUCTION. /� - --' <br /> PUMP INSTLATION PUMP REPAIR �/ PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. a Cable Tool r.. -,_-Dia.. of Well'Excavation A <br /> _ Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _'Irrigation i Gravel Pack Depth of Giout Seal <br />_ -Other Rotary Type of Grout <br /> Other r Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump £"T' - -- --- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done l / C_- <br /> - -- <br /> ,DES.TRUCTION OF WELLe Wei I3iame1t_er _ T ' 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 <br /> Krdt _ �� TITLE <br /> (D LOT PLAN ON REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE I 271'l <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT1tNSPECTIWPHASE II FINAL INSPECTION <br /> INSPECTION BY V DATE INSPECTION BY tiffDATE 27__-7'L- <br /> CALL <br /> LCALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 7/72 1M <br />