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SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR OFFICE USE: 1601 E. Hazel tor�:'.Ave. ;'.';-Stockton, Calif.
<br /> Telephone
<br /> APPLICATION FOR WELL.,CONft.RUCTIONfs'OR PUMP PERMIT Permit No. Li
<br /> 71-4'1-
<br /> THIS
<br /> 71-41-7,THIS P-ERMIT.)-E-XP-IRES,,,,,I!tY,,E-A%R,5FRQM,.:DATE--,;,,ISSI-JEIY,-,_,,1 u'e'd
<br /> rV -7
<br /> Applicati.,ohs.),,iba.,hbreby:t.made7l-t-o
<br /> and/or install the work here'in describ(id. Thlbti(app,11 c;at&1ohv.1s,,�mad e*k-in-cioinplian ce...'vith'.,S-an'Jbaquin
<br /> County,.�.9r,di-na'n,c,eo,NoF.,�ql*862--iifatf'dti,,thEttik.ull:ei�,atidr-',R�--'gul'A,t-ifons-�)-bao"the -Sa-nfJ'Oa�qiiit,-�L6ta'l''H"eAl,th=Dist-rict;
<br /> bXd1'apot! -F �o
<br /> �M CENSU&�-TRACVO
<br /> JOB ADDRESS/LOCATION —KOS_kEA? -DO 4 "s
<br /> gbI , �t
<br /> - oia �
<br /> Owner! n J
<br /> Address h44CU city
<br /> Contractor's Name License # Phone
<br /> TYPE OF WORK (Check) : NEW WELL /;�'DEEPEN RECONDITION DESTRUCTION 1-7
<br /> PUMP 'INSTALLATION PUMP REPAIR '/ PUMP REPLACEMENT
<br /> Other.
<br /> DISTANCE TO NEAREST: TANK' `. 50 SEWER LINES PIT PRIVY
<br /> SEWAGE DISPOSAL. FIELD- CESSPOOL/SEEPAGE PIT;
<br /> OTHER
<br /> INTENDED. USF, :' ".TYPE OF WELL', CONSTRUCTION' SPECIFICATIONS
<br /> Industrial__', Cable Tool Dia. ,of Well. E-kcavation
<br /> Pomestic/private
<br /> Drilled Dia, of Well Casing
<br /> ' Dbmestic/public Dftveh Gaiuge of Casing
<br /> Irrigation aye
<br /> Gr l:Pa6k ,.. Depth of Grout Seal
<br /> Other Rotary..,. Type 'of Groiit
<br /> Ofhiet Oth6i Inifor'mation
<br /> PUMP INSTALLATIONi. :' Coiitiactor
<br /> Pump H.P.
<br /> Type of.
<br /> PUMP REPLACEMENT: •
<br /> 7 8, tate Work Done
<br /> PUMP REPAIR: State Work Done
<br /> DESTRUCTION 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 Distridt
<br /> andithe State' of California pertaining to or regulating well construction. . Within FIFTEEN DAYS
<br /> aft6r"compleeiori of. my' work on a new Well, I will furnish the San Joaquin Local Health Distri_ct a
<br /> WEL1 DRILLERS REPORT of the well and notify them before putting the well in use. The above
<br /> information is tru to. the best.' of j2v1knowledge and b,elief
<br /> SIGkDr-
<br /> �) . . — . . . I ; TITLE:
<br /> (DRAW PLOT �PLAN ON REVERSE SIDE)
<br /> ;FOR DEPARTMENT USE ONLY
<br /> PHASE I
<br /> APPLICATION ACCEPTED BY 2 =DATE
<br /> ADDITIONAL COMMENTS::
<br /> ILL
<br /> PHASE -II -GROUT INSPEtT= PHASE III/FINAL INSPECTION
<br /> INSPECTION BY DATE
<br /> INSPECTION B DATE :23
<br /> CALL F .OR A GROUTINSPECTION PRIOR TO GROUTING AND FINAL IeCTION.
<br /> E H 1426 4/72 1M
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