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SAN JOAQUIN LOCAL REALTX. DISTRICT. <br /> .FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone: (209) ;466'6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> s <br /> V THIS PERMIT EXPIRES 1 YEAR F :OM.DATE 'ISSUED Date Issued �I� <br /> �, (Complete In Triplicate) <br /> tAppiication .is hereby de 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 /> JOB ADDRESS/LOCATION l p &6 r�( S _ CENSUS TRACT <br /> V . <br /> G "! <br /> �Y,. <br /> Owner's Name ' ' Phone <br /> Address {�G $ rh City ! L7 L.� G!� ' <br /> i <br /> License- . # p ZPhone 'X14 Z`3;i-7�� ' <br /> Contractor's Name <br /> y . <br /> s <br /> _ a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/ / RECONDITION DESTRUCTION {� <br /> PUMP INSTALLATION / PUMP REPAIR / { PUMP REPLACEMENT /? <br /> Other / { <br /> DISTANCE TO NEAREST: SEPTIC TANK J5'61 SEWER LINES `a U t PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation C <br /> Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other =e' Rotary Type of Grout G MfIV 7- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor (J U �. <br /> Type�•of4Pump U H.P. <br /> ; � i s <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: . /7/ State Work Done <br /> ESTRUCTION OF WELL: ...:,Well Diameter' Approximate Depth <br /> Describe Material and Procedure <br /> r� <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' 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 /> `�: •,.�-.¢ �' '�;b�� r; i, <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE l ! <br /> ADDITIONAL COMMENTS. <br /> PHASE'II GROUTtINSPECTION PHAS III/FINAL INSPEC- <br /> INSPECTION BY DATE �,',° , 1 r�,. '�` INSPECTION BY h DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 V 4/72 1M <br />