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iSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. y <br /> 11'. Telephone: (209) 466-6781 k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3-� D <br /> THISI�PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r_o_7� <br /> ,,_'7M*__r5;S7W— -f-W� tg (Complete In Triplicate) <br /> Application is hereby made to he 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 andil'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J, �rul . iU J�� re atf S�'U' -- $pcGCENSUS TRACT e"!- <br /> y <br /> _ <br /> Owner's Name A II� ���� - _. ._ Phone 7G� /7. <br /> Address J�i� - Q II dG �YL .� City -- i <br /> Contractor s Name <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WEIIL /� DEEPEN /_7 RECONDITION /_7 DESTRUCTION /- <br /> Other <br /> PUMP REPAIR / - -- - � <br /> /�/ S i <br /> DISTANCE TO NEAREST: SEPTIC SANK SEWER LINES PIT PRIVY <br /> SEWAGE BIISFOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6� } <br /> INTENDED USE TYjPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'I1! Cable Tool Dia, of Well Excavation <br /> Domestic/private :Lb Drilled Dia. of Well Casing <br /> 4 Domestic/publicNt. _ Driven ` Gauge of Casing <br /> Irrigation SII% • Gravel Pack Depth of Grout Seal <br /> Other ill, Rotary Type of Grout _ <br /> 'I1I _ Other Other Information <br /> � �_ <br />� PUMP INSTALLATION Gontra ��ltor ��/"�f/��-f' F 4) <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: an <br /> rLUMWork <br /> REPAIRS ¢ S / State Work Done <br /> i <br /> + ,DESTRUCTION OF WELL: Well-IDiameter Approximate Depth <br /> Descrie Material and Procedure <br /> I hereby agree to comply withilall 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 All and notify them before putting the well in use. The above <br /> information is true to the bei t of my knowledge and belief. <br /> SIGNEDC TITLE 4A <br /> D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �. DATE <br /> ADDITIONAL COMMENTS: IIS <br /> PHASE II GROUT INSPECTION P ­11)[/FN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE J-y.-7 _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ., <br /> E H 1426 jil 7172 1M <br />