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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> (/ 1601 E. Hazelton Ave.-; Stockton, Calif. ? <br /> FOROFFICE USE: <br /> Telephone:, (209}�,4`6'6;"6781 <br /> APPLICATION FOR WELL CONSTRUCTiON 'OR PUMP. PERMIT Permit No.71 <br /> THIS PERMIT=,EXPIRES'.l-XEAIt,FROM DATE IS5UED>�= .F 'V-)Date Issued : r <br /> - i <br /> (Complete Iii'Tfp irate} i L,: <br /> Applicat,ioz�t�yis.:herebyrdeaa "tha} a�aJ'oaqunfl.ocal lie,alfh Dstr.ict�.for.,a..perinit 'to-;constrict <br /> i <br /> and/or install ,the workherein described. Thli mappJ.jcatjonres-' dez.in?c�mpliance .wx-th'`San`lJoaquit► ' <br /> ;. es' andi=lte u�ations,�of the San'Joaquin Local Health F District: 1 <br /> County--,grdina�ciCeDNo 1'862 ands he-:1 E _ i:_. ;p 3 �.9r <br /> (7v •-.t1:i <br /> T c:,CENSUS TRACT 1 D <br /> JOB ADDRESS/LOCATION 4 <br /> V <br /> y, <br /> Owner'.a.1.N4me r <br /> City_ <br /> Address <br /> License ��, Phone '. <br /> Contractor's Name ° fi - <br /> • W WELL./ I -DEEPEN;/_-,/ -RECONDITION ptST UC,TION 77 —� z <br />-4 TYPE OF_ . (Check)_Y_ E <br /> �--— <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / PUMP 'REPLACEMENT : <br /> DISTANCETONEAREST: ' SEPTIC TANK--.- (SEWER LINES$! 7r;Z, PIT PRIVY 1 <br /> ]SEWAGE: DISPOSAL, FIELD, CESSPOOL/SEEPAGE PIT,.. OTHER <br /> INTENDED` USE gTYPE OF WELL ;. CONSTRUCT,ION'`SPECIFICATIONS <br /> ,. Industrial. <br /> *. � Cable Tool DiaII Well..Excavation <br /> ---- Drilled `Dia o Wel Cas ng <br /> _ S <br /> Domestic/private `K- <br /> 1 ; • _ Gau e of Casing <br /> � �Dmestic/public . Dxi�en�" E <br /> Irri anion ' 4. ` ' j'.q�'avel Pack Depth .of'. Grout: Se l :.. <br /> ..Rota y '�...TYpe of Grout ' <br /> �. <br /> _ Other' ---"` ' Other In ori <br /> ' Others_ i f . r..a. <br /> PUMP INSTALLATIONa . C6htr'actor H.P..; . <br /> 0`,. ` Type. ' <br /> a , <br /> PUMP REPLACEMENT- / /4"`S tate 1Tork;Done <br /> PUMP REPAIR: / / State Work Done _ ..,..,�.,.r <br /> 1 Approximate Depth <br /> .DESTRUCTION. OF WELL': i Well Diameter i <br /> ,Dscribe Material and Procedure <br /> _e <br /> 1 <br /> I hereby agree t0 comp].y .with. all laws and regulations of the -San 3oaquin Focal Health District <br /> i and?the State of-Calfaini"a.perfasiiingtar regu3,atiing well construction. Within FIFTEEN. DAYS <br /> after�rcomp.letion of,,I w6tk bn a new w.ell,. I�wiil. furnish the San3oaquin Isocal Hearth bovtric;'t�a <br /> WELL.DRILI;EItS REEORTof-`'the wellandrnotify them before putting the well in use. . The .move <br /> information." Gr' etp tihe best.,of`"my knowledge.and belief.:, ; <br /> , TITLE <br /> SI ED I `\(DRAW PLOT PLAN,ON REVERSE SIDE)t7 <br /> 'FOR DEPARTMENT USE ONLY ! i <br /> ' <br /> PHASE I ^r r. <br /> y,,. ��. •�: ' -.� ��- �r"�. �--,.._ DATE <br /> APPLICATION ACCEPTED, <br /> ADDITIONAL COMMENTS: PHASE TII/FINAL :II35PECTION <br /> PHASE II�GROUT INSPECTION INSPECTION BY DATE "; '7 <br /> INSPECTION BY DATE <br /> CALL_FOR <br /> INSPECTION..PRIOR.TO GROUTING AND FINAI:r INSPECTIOI3 <br /> A <br /> __.,_.. _ .,_. ... w _._.., t, .. 4/72 lM <br /> E H 1426 <br />