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j� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-'.Ave-.,-, Stockton, Calif. <br /> - Telephone x;(209) 466=6781 <br /> PLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 751� <br /> THIS.PERMIT :EXPIRESe`Ii;YEAR FTtON'DATE ISSUED, Date. Issued �]`7 `�7y <br /> t; rs�?�3�z'(Complete:a'In�Triplicate) <br /> Application is hereby made .to the San Joaquin .Local,.Health District.Lfor a permit to ,construct <br /> and/or installthe,.work,hherein,_:described. jhis applicatiori,.is.;made incompliance with SanJoaquin <br /> County OrdinanceLNo,,il862,:.andathe�Rules►ands?Regulations:�of-',the San- Joaquin -Local Health District. <br /> .TOB ADDRESS/LOCATION ?!s� t. 5 /�if/� P !cif f 1k. CENSUS .'TRACT <br /> .�_.+_ s e•-;. L .wx. y;- A� ..�.�'"�-'�I41 ZS) `— '�:Y�.i"?,f Lq ;3 yr.- F<��i .:c.r .:�-. .. [.... _ : ', . _ <br /> Owner's Name 11 � .• � Phone <br /> Address-- <br /> ddress_ 1.JC4 SC x s�7' rPnJcC� c -� - City <br /> U versa / <br /> Contractor's Name License ��Z6 761 Phone V( - <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN -/7--/ RECONDITION /: / DESTRUCTION ,/7f� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT :1_/ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK/Da SEWER LINES 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 <br /> Domestic/privatel3 Drilled Dia, of Well Casing <br /> Domestic/public l Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 'u Other Other Information ' <br /> k <br /> I. <br /> PUMP INSTALLATION:: :,Contractor <br /> r ('.Type of Pump S e't r3 H.P. ¢{ <br /> !I �� <br /> .PUMP REPLACEMENT: �� Mate Work Done .� v�` L�rC�p /� OYP2AZjn&d0V if <br /> w Sy l�tp/zS1�ho, <br /> f PUMP REPAIR: State Work Done <br /> !9 <br /> k ,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 /> t I will furnish the San Joaquin Local Health District a <br /> after completion of my"work on a new well, <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 f my knowledge and belief. <br /> SIGNED TITLE _ <br /> j (D T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I� f• DATE 17,APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: :i! <br /> PHASE II GROUT INSPECTION PHASEII ,f FINAL INSPECTION <br /> INSPECTION .f DATE INSPECTION BY A 7� <br /> ... . <br /> CALL ' � A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426' �I /72 1M <br />