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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> t <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z= 35p <br /> _ THIS PER 1 YEAR FROM 'DATE ISSUED Date Issued � <br /> 1 W,._..� . . .. <br /> J 33 0'Ow ., N{ , c�.4- �. (Complete In Triplicate) /�- �y <br /> Application is hereby-made-to the San,.Joaquin Local Health District fora .permit to Construct <br /> and/or install the work herein described. This application is made -in compliance with San Joaquin <br /> L County Ordinance No.• 1862. and: ­the. Rules and ire ulations of the San Joaquin Local Health District. <br /> -n-v-� r <br /> 30B ADDRESS/LOCATION ' f �NSUS TRACT' <br /> Owner's Name <br /> Phone <br /> t r] <br /> Address 0 0 <br /> -- - . w _ l✓ ;' .j _ _ City ,_, -. <br /> Contractor's Name •-F �� <br /> � _j License` 1177 O Phone Z2, 7J 1 <br /> r <br /> TYPE OF WORK (Cheek),: NEW WELL / / ;DEEPEN /__/ ' RECONDITION /7 DESTRUCTION /`7 t <br /> PUMP INSTZU, ION W/ PUMP REPAIR / / PUMP REPLACEMENT /_7 UJ <br /> Other <br /> DISTANCE TO NEAREST:}. SEPTIC TANK N.SEWERLINES PITPRIVY <br /> ' - I <br /> SEWAGE DISPOSAL 14-dD. m`1_ 06_ESSPOOL/S.EEPAGE PIT OTHER <br /> INTENDED. USE`- '• TYPE OF WELL - CONSTRUCTION,SPECIFICATIONS <br /> Industrial ~-Cable Tool Dia. of Well--Excavati6n <br /> Domestic/private Drilled Dia. of Well Casrn� . <br /> ` Domestic/public Driven Gauge of Ca'siAgO' <br /> Irragtion -Gravel .Pack Depth of Grout Seal— — -' <br /> �Other '� Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump JE 1, H.P. <br /> /17 <br /> PUMP REPLACEME / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> } <br /> I hereby agree to comply withall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within F'IF'TEEN 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 -.be-fore putting the well in use. The above <br /> information is true to theKest of my knowledge and belief. <br /> I <br /> SIGNED ; <br /> %�` TITLE <br /> (DRAW PLOT PIAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 113 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE /FINAL INSPECTION r <br /> INSPECTION BY DATE INSPECTION BDATE (07/ j--?j <br /> CALL FOR A GROUT INSPECTION PRIOR TO GkOUTI G AND FINAL INSPECTION. <br /> E H- 1426 4/72 1M <br /> 4 <br />