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r` SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> FOR OFFICE USE: V/; 1601 E. Hazelton Ave. - Stockton, Calif. <br /> Telephone: (209) 466-6781 F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED Date Issued <br /> (Complete In Triplicate) ; <br /> Application is hereby made to �the San Joaquin Local Health District for a permit to construct � <br /> and/or install 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 San Joaquin Local Health District. <br /> S; <br /> ,JOB ADDRESS/LOCATION3L1F,3l TanrZ, Tri . �.Y►_ ,� ;��F CENSUS TRACT <br /> Owner's Name - � --- - - ` - � � ^ phone <br /> 1I' n i g ati*+ <br /> AddressCity <br /> — l (i Saticoy-- - -- - SWIV <br /> Contractor's Name 91352 <br /> License # Phone , <br /> �a��ac .,., 147500 <br /> 635 <br /> TYPE OF WORK (Check) : NEW WELL /J[/ DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> . -PUMP INSTALLATION/ / CRUMP,REPAIR./7/ PUMP REPLACEMENT /� <br /> Other <br /> _ w <br /> DISTANCE TO NEAREST: SEPTIC'TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PIT OTHER j <br /> t I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation 6-,>f <br /> 'X Domestic/private i Drilled bia. of Well Casing g l . <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal.. . . <br /> Other , Rotary Type of Grout B�henifie <br /> I Other Other Information <br /> s <br /> PUMP INSTALLATION: Contractor Hart Electric <br /> Type of Pump H.P. 36 hp. <br /> rrr <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP REPAIR: / / State Work Done <br /> A. <br /> .DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and'Pacedure " - <br /> lk- <br /> I hereby agree to comply with all laws' and regulations of the San Joaquin Local Health Distric, <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 Health District <br /> WELL DRILLERS REPORT of the well and notify them before .putting the well in use. The above <br /> information i rue to the best of my knowledge and belief. <br /> SIGNED TITLE , T <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l ( 0;_4 05 L-/ /V. > T R DATE , <br /> ADDITIONAL COMMENTS: _e�af 1777 <br /> PHASE II GROUT INSPECTION P S lif <br /> tPAL INSPEC 2 � <br /> INSPECTION BY DATE INSPEC ION DATE ' --1✓ ` . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72' 1M <br />