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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OtICE SE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: (204)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,�,-��2/J <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 pe'rmit `to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ands the Rule �, u7,ati�gip oft�e�5an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION G 177 CENSUS TRACT <br /> Owner's Name �/_lG"j f L ��' Phone <br /> Address e L2 ! _ F' 4,z&_o City 3 dei , Qll <br /> Contractor's Name �1r � �ls4�A License <br />/ TYPE OF WORK (Check) . NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other % / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial +f Cable Tool Dia. of Well Excavation <br /> Domestic/private i' Drilled Dia, of Well Casing <br /> Domestic/public 1: Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout ��_ 7"CPa Ml -e <br /> Other -Other Information ' <br /> i eb <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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,-Rva:th`"'Di.stricf f <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 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 .est of my knowledge and belief. <br /> SIGNED r TITLE 6"'1(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE 9 3 <br /> ADDITIONAL COMMENTS: <br /> PHA I G UT SPECTIO _ PICAS III FINAL INSPECTIO r <br /> INSPECTION BY DATEZZ3 b, <br /> INSPECTION BY DATE j <br /> I <br /> CALL FOR A GRO INSPECTION PR OR TO GROUTING AND FINAL INSPECT <br /> E H 1426 +7/72 1M <br />