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Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF;OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 3 7s <br /> Telephone: (209) 466-6781 73 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-3?,)- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/1 7 <br /> (Complete In Triplicate) <br /> Application is hereby made 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 Joaquincal Heq th District. € <br /> JOB ADDRESSILOCATION f.� � � /V1?qn¢�' , US TRACT s <br /> d <br /> Owner's Name Za-WiPhone ��i7(Y <br /> Address . . <br /> City <br /> a <br /> Contractor's Name License # Phone J <br /> TYPE OF WORK (Check) : ,.,NEW WELL DEEPEN -/ / RECONDITION I_I DESTRUCTION I� <br /> -�. PUMP. INSTALLATION / J PUMP REPAIR'/ J PUMP REPLACEMENT /_7 � <br /> �• -Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK / d SEWER LINES .PIT PRIVY <br /> _'_SEWAGEDISPOSAL FIELD- 12.12.CESSPOOL/SEEPAGE 'PIT' `OTHER <br /> INTENDED :USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation _ j Z <br /> /Domestic/private Drilled Dia. of Well Casing <br /> Domesticrpublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other # Rotary Type of Grout <br /> Other Other Information " --- <br /> . PUMP INSTALLATION: Contractor. <br /> Type of Pump J H.P. . .d.. 1 <br /> PUMP REPLACEMENT: / / State Work,Done <br />"'.`PUMP'TtEPAIR:' <br /> .DFGTRUCTION 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 per•taining;to or -regulating well ''construction. Within`FIFTEEN DAYS <br /> after completion of my work on a new we11,, 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 /> /�/ <br /> SIGNED TITLE <br /> iZ (DRAW PLOT PLAN REVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I -� <br /> APPLICATION ACCEPTED B C DATE 7 ! <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY a4,911 DATE 7 <br /> ....CALL TOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E K 1426 _- 5/731M t <br />