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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.15-7,L- 1522514 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O-l/73 <br /> (Complete In Triplicate) Q&-,�— l f-V­tk T <br /> Application .is hereby rade to the San Joaquin Local Health District for a permit to construct <br /> and/or ins-tall 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. Sant Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATIONAl <br /> , CENSUS TRACT <br /> Owner's Name C&:6_ --- __ Phone <br /> Address _ �f 0 �' _'IL_ _ City <br /> Contractor's Name I w" License #! "--Phone '{ul <br /> TYPE OF WORK (Check) : -NEW WELL/ / DEEPEN/ / RECONDITION l / DESTRUCTION <br /> PUMP INSTLATION �/ PUMP REPAIR '/ / PUMP REPLACEMENT /� <br /> ALt" <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 Toole 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 /> j Other ; Rotary Type of Grout <br /> Other Other Information - <br /> � PUMP INSTALLATION: 'Contractor •�3-�7a1 G�` . <br /> E Type of Pump H.F. iL ` <br /> PUMP REPLACEMENT: LA State Work Done - <br /> PUMP State Work Doneo- <br /> r1 a. <br /> DFgTRUCTION OF WELL: Well Diameter,,. Approximate Depth <br /> L 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 Hearth District t <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 nd lief. <br /> SIGNED LEi�'e9lg . <br /> (DMW T PLAN ON R RSE SIDE) <br /> FO& DEPARTMENT USE ONLY <br /> a PHASE I <br /> APPLICATION ACCEPTED BY DTE <br /> ADDITIONAL CO;,MNTS: <br /> PHASE II GROUT INSPECTION PHA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> # CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN . <br /> . V u z A?A 5/731M <br />