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' SAID JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOR OFFICE USE: 1601 E. Hazelton`Ave.'; ;Stockton, Calif. ' <br /> Telephone (209)'. 466,6731 i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIJ Permit No. 7Z��I� <br /> 4 <br /> t <br /> THIS PERMIT EXPIRES .I.1YEAR.FROM D�Vf.E -ISSUED Date Issued(,, 3 -7 <br /> Al :. Y ,_ (Complete In Tr plicate) ` <br /> ApplicationE�i6,.hereby,.madextoIthec,1San�TJoaquin'.,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.,;1862and' th.6 Rules'-,-and,-Regulations of `the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !a . - CENSUS TRACT ' <br /> '�'. ti'�"' " "�fl::eo�i7�; �-g•1 hj� C}�Y'! .'�t.i.�I .. ..7 x s. "L., M •- f <br /> Owner'ss•Name: t j-i` :ts ,xf1, 4 S^�:.,,rc r Phone _. <br /> Address. <br /> f� �Cc 22 �-�� - City -- <br /> Contractor's Name License # I Phone 14G_ G.,�,S <br /> E <br /> F <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN;// AECONDIT-TON DESTRUCTION /7 <br /> ALy <br /> PUMP INSTALLATION /k/ 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 OF WELL CONSTRUCTION SPECIFICATIONS <br /> E Industrial i- Cable Tool Dia.. of Well Excavation <br /> Domestic/private f Drilled Dia. of Well Casing dam <br /> Domestic/public i Driven Gauge of Casing S ` <br /> Irrigation = Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ' Other Other Information ' <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> / �f <br /> PUMP REPLACEMENT: I1 / State Work Done <br /> j <br /> PUMP REPAIR: / / State 'Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 3 <br /> ' I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District l <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 best .of .my knowledge and belief. <br /> ams/ <br /> i SIGNER TITLE <br /> (DRAW PLOT PT, ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE�Y <br /> APPLICATION ACCEPTED BY DATE a <br /> ADDITIOfiAL COMMENTS: <br /> PHASE XI GROU INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S <br /> CALL FOR A GROUT INSPECTION_PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 ;. . . 4172 IMO <br /> t <br />