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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOk.:OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRi3CTI0N OR PUMA' PERMIT, Permit No. -7y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued A - 2 d-7o- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> axed/or install the work herein described. , This application is imade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> L <br /> JOE ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name '/ ./�.._/ 2 J1/k U - - -- Phone - ;� <br /> Address 5L-2°1 � T Z�. 1 -- city ,Lp <br /> Contractor's Name C/A IE/ -W,5X4 "Y .eQ_U/If G:_ License 'f" Phone YW12>SS � <br /> TYPE'OF WORK (Check): NEW'GIELCW DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> f PUMP INSTALLATION / f PUMP REPAIR / I PUMP REPLACEMENT — <br /> f — <br /> Other' / I <br /> DISTANCE TO NEAREST: SEPTIC TANK_32(2Lf- SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES SEOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE jTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool' Dia. of Well Excavation 12 <br /> .Domestic/private Drilled Dia. of Well Casing 12 <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation r Gravel Pack Depth of Grout Seal <br /> "7''--" Other Rotary Type of Grout , <br /> — -- Other Other Informations <br /> PUMP INSTALLATION: Contractor <br /> Type" of Pump H.P. <br /> PUMA'. REPLACEMENT: / /i State Work Done <br /> t <br /> PUMP VPAIR: / / State Work-Done <br /> DFSTRUCTION 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 /> r 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 l. _ rn <br /> wilfuish 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 /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �. <br /> PLICATION ACCEPTED BY �p Lwj DATE /W741 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY Aeof DATE P71elnl <br /> - CALL-FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> u ��,�ti • 731 <br />