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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone ; (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: ?�7z� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;Z 1G y� <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 Ithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,� O V,"s P ,jP c a CENSUS TRACT <br /> f� ' Phone eft 3�G 7�s <br /> Owner's N �c ame �al'�® ,NY'OS ._ <br /> Address C1 fl � City Za 4166 a <br /> Contractor's Name r �i d0 C�aM Ak License #,7.E 977 Phonal 3.3 11" <br /> IF <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN /_/ RECONDITION /-7DESTRUCTION /_7 <br /> PUMP INSTALLATION /(/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK L 0 SEWER LINES0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD G ,SD CESSPOOL/SEEPAGE PIT .,�CJ OTHER .� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ::]Zndustrial Cable Tool Dia: of Well—Excavation 1 ZQ ` <br /> Domestic/private 1 Drilled +Dia. of Well Casing <br /> Domestic/public -Driven Gauge of Casing r` r <br /> Irrigation 1 Gravel Pack 'Depth of Grout Seal ' Q <br /> Other' 1 Rotary 1 Type of Grout rp <br /> 1" Other Q�rn begott Other Information <br /> PUMP INSTALLATION: Contractor i} �.Ioek 6V <br /> Type Of Pump - H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP REPAIRS / / State"Work- Done <br /> � <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 District <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 Sn 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 4tothe est €,my.-knowledge and belief. <br /> TITLE <br /> SIGNEDY.. . <br /> rl. <br /> - (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R .DE. :::PARTMENT USE ONLY- <br /> PHASE <br /> NLY ' <br /> PHASE I 1'•r _ <br /> � APPLICATION ACCEPTEDR FBY - _ ,.;. '- _-- -- - DATE / 3C 7 <br /> ADDITIONAL COMMENT r <br /> PHASE fl GROUT INSPECTION PHASE F NAL INSPECTI N <br /> INSPECTION BY _ DATE' . INSPECT:WN BY, DATE t 7 <br /> CALL FOR A GROU' INSPEC I'UN P,R Qk� ,TO.,GROU'T-ING''AND FINAL INSPECTION. <br /> E H 1426 .� -- #.A `.. r..,,», �.. 1�_ 772 _ r <br /> �{ :,— <br />