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<br /> FOR ..GFF,.ICE USE: 601 E.
<br /> Z-1
<br /> 3
<br /> F- SAN JOAQUIN LOCAL Hazeltot�-�.Ave. Stockton,HEALTH DISTRICT
<br /> . `.� ockn, Calif.
<br /> ;30 1. '
<br /> Telephonet., (209),,-,4,66�-67bi"
<br /> ,
<br /> ICATION FOR WELL CONST -,RUCTION�-CiR PUMP PERMIT Permit No. 9(5
<br /> THIS PERMIT-M, IRES:-i It YEAR-],FROM, DATE yISSUED ,",0 JrDati2i',Issued
<br /> 13;jo
<br /> Applicatioft!�it-�,h6 e-bysma eito then-San,JbaquinlcLocal Health Dl'-strict=for'-a-1pe'r- 'Mit. tb
<br /> and/or install the work herein described. Thisl:app-
<br /> licaxion,.,is�,made inc compliance 1 with, SlarirJoaquir
<br /> -i
<br /> County,,.,PrdinanceoNo-,rl862r.-iah-d-�,,.,,the., Ru,le's�land,,,.,Regula -the, San-3JoaquinLocal lHealth 'D" ict., ji t
<br /> I . ,.�-4
<br /> A
<br /> 0,y 2" I'DIPIV6& i'l�OF.NSfJ.S:�TRACT,,/�,/-/`v/-/
<br /> JOB ADDRESS/LOCATION X�
<br /> Owner,s
<br /> a—,,7��2 d 1-;7V F11 d joa-
<br /> Nam601," ,�u fte-'
<br /> Rt
<br /> Address Cit
<br /> Al,
<br /> Contractor'sName X-Al2 License # Phone-Z fu-Txy
<br /> RECONDITION DESTRUCTION /-7
<br /> TYPE OF WORK {Check) : NEW WELT DEEPEN--'/
<br /> PUPUMP-INST�ILATION X/ PUMP REPAIR PUMP REPLACEMENT -7
<br /> Other' /
<br /> k
<br /> DISTANCE TO NEAREST: 'SEPTIC TANK-ZM SEWER LINES PIT PRIVY
<br /> SEWAGE: DISPOSAL,FIELD CESSPOOL/SEEPAGE PITOTHER
<br /> 4 INTENDED USE TYPE OF WELL' CONSTRUCTION SPECIFICATIONS
<br /> Industrial. .. Cable',Tool Dia
<br /> of Well Excavation LA
<br /> Domestic/private, Drilled Dia. of Well Casing
<br /> Doinestic/Vublid Driven Gauge of Casing
<br /> Irrigation Pack . Depth' of, Groiit. Seal
<br /> f Grout
<br /> Rotary - Type b
<br /> Other
<br /> Other Other� -Information i
<br /> %
<br /> PUMP INSTALLATION:/', Contractor
<br /> zz—
<br /> iype Of PUMP. H.P.
<br /> v
<br /> PUMP; REPLACEMENT: State Work Done
<br /> PUMP REPAIR: *4,-
<br /> State Work D.6ne
<br /> 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/Realth District
<br /> and (the State of, California -pertaining to or regulating well construction. ,` Within FIFTEEN DAYS
<br /> t '1 Health District a
<br /> after completi6n of my work On <a new well'. I will furnish the San Joaquin Loca
<br /> WELL DRILLERSREPORT of the well and notify them2,befoie putting the well. in use. The above
<br /> information is true; to the bestf of ;my ioknowledge; ar�d,belief
<br /> SIGNED TITLE
<br /> V(DRAW PLOT PLAN ON REVERSE SIDE) ,
<br /> FOR DEPARTMENT USE ONLY/
<br /> PHASE I
<br /> APPLICATION_ACCEPTED by DATE
<br /> ADDITIONAL &;MMENTS:
<br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION.
<br /> INSPECTION BY DATE INSPECTION BY DATE
<br /> CALL FOR k GROUT -INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. —_
<br /> i-g-1426 4/72 1M
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