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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r-,(T1 .01zF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y_L_3!� 4/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j_2.7-;4. <br /> (Complete In Triplicate) <br /> Application is hereby nade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is rade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> ,TOB ADDRESS/LOCATION Z. (0 -7 V " 7'I CENSUS TRACT ' <br /> Owner's Name fV1 R S j R 1 �►-- �� c- Phone '1L1 - "! �/3 <br /> Address es W "P, a 111 4-0 0_.D city S 'rfT 1'1/ <br /> l <br /> i <br /> Contractor's Name S T14tV F► v`Z-L� - - � 00 License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR "/_/ PUMP REPLACEMENT /_ <br /> Other / / $ <br /> � i <br /> DISTANCE TO NEAREST: SEPTIC TkKK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> InZ17ustrial Cable Tool Dia. of Well Excavation <br /> [ 7i <br /> ot�nestic/pxivate.,T 4 .tip, Drilled Dia. of Well Casing <br /> � mestic/pub13' w Driven Gauge of Casing - --- - <br /> rigation. z ' S`a '^ Gravel Pack Depth of Grout Seal <br /> �Other F` M1 T77 Rotary Type of Grout <br /> Other Other Information ' <br /> PUMPr,INSTALLAT16N:" Contractor, QQq ; <br /> Type of Ptiuip .. .H-;P- <br /> n.I t <br /> PUXI -'REPLACEMENT: / / Sta.te2 Work Dome ' <br /> PUMP 'CEPA��t ' S6 _ <br /> � / I �at� Work hone , <br /> .DF•fiTRUCTION bF WELL:... Well. Diameter <br /> Approximate Depth <br /> Describe- Material and Procedure <br /> Ihereby agre'e`. to; comply with .all laws and regulations of the"Sail-•J6aqu1n Lvcal..Health Dis,tr ct1 <br /> a d the State *of California pertaining to or regulating well -con t action. ;Within FIFTEEI�`ay's <br /> j <br /> ka fter -completion df my work on a new well, I will furnish tt�e'Sa ,Joaquin}Local. HealC�r' 7la�:t�ict a_r <br /> I, -?.L DRILLER R!POAT'of-ih�' well and notify them before putting the 'in 'use.. 'The,-abo4 <br /> for ation is tri'e oto, u' best of my knowledge and belief. <br /> 1 jv x. <br /> SIGNED r :. , <br /> TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDLE) r =' <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY DATE 3 ZsZ�- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IWEUIAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY jLj DATE2�7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> 11 it 1AIK <br />