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Jw" 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. _ �t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f�CJ z,�',S> "ECrJtO.J. *0 t (Complete In Triplicate) 6-5o <br /> Application is hereby made to the San Joaquin Local Health District f�oorr 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 <br /> o�►r u �/ ENSUS TRACT <br /> Owner's Name ` ' �r wa—vim"e <br /> p 11 cQ1 � Phone t� "F — 98;L—g Co <br /> Address /a60 _ �` � �- --._ City S.0d . <br /> Contractor's Name License # aA7_�i~Phone Ak-W74 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / f PUMP REPAIR / f PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout f: <br /> Other Other Information <br /> Q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP iq / State Work Done tZ o 4-r-) <br /> PUMP REPAIR: / J State Work Done <br /> .RESTRUCTION 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 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 knowied e a belief. <br /> SIGNED s. ITLE <br /> PLOT PLAN ON KiOERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Z�� <br /> APPLICATION ACCEPTED BY DATE �-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOX PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / w�dw,,.,. DATE ef <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />