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_ SAN JOAQUIN LOCAL HEALTH DISTRICT ik� kq q <br /> E I..OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. jq_c.tt�(3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -73 <br /> (Complete <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 /> .TOB ADDRESS/LOCATION g H01-01 FtR f , �r j �(� ygZ, � a-IISU CENSUS TRACT f Z4-<aD 43 <br /> Owner's Name .L c x Phone <br /> Address '601114sr rjq� = Ti_v'aa.. t.4 L�f� Ilzq City 5t4-Ncl? <br /> Contractor's Name it L A-RA L FU L_ ¢ E stip License # Phone 17 <br /> f <br /> TYPE OF WORK (Check); NEW WELL / DEEPEN '/—/ RECONDiTION / -/ DESTRUCTION /?.- <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENT /_7 <br /> t Other /A. <br /> a <br /> n <br /> DISTANCE TO NEAREST: ; SEPTIC TANK SEWER LINES 30014- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. � Cable Tool- Dia. of Well Excavation -- 4-1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing --- 3 d./TS <br /> Irrigation Gravel Pack Depth of Grout Seal �PZ°rr <br /> Other Rotary Type of Grout [1- � <br /> Other Otherrinformation .j <br /> a t <br /> PUMP INSTALLATION: :— _C 'tractor <br /> H 4 b elTYpe of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: <br /> / /'-State Work Done <br /> .DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> € Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulation's of the San Joaquin Local Health District <br /> and the State ,of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work an a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL DRILLERS REPORT ofathe well and notify them before putting the well in use. The above <br /> informatio s tru to rhe 'b`es my, knawiedge and belief. <br /> i <br /> SIGNED r TITLEc <br /> (DRAW PLO , PLAN ON REVERSE SIDE <br /> F'0 DEPARTMENT USE ONLY <br /> PHASE I r i <br /> APPLICATION ACCEPTED .B A DATE � 4 3 <br /> ADDITIONAL COMMENTS el rCzgj f tX <br /> PHASE 11 GROUT INSPECTION PHASLf III FINAL INSPECTION <br /> INSPECTION BY T� -' DATE I SPECTION BY DATE .///147-3I <br /> - CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> '% <br />