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i SAN JOAQUIN LOCAL HEALTH DISTRICT A <br /> FOR OFFICE USE: 1.601 E. Hazelton, Ave.%• Stockton, Calif. <br /> Telephoine .`-, (209"T 466'-67Sl <br /> PLICATION FOR WELL CONSTRUCTION-:OR PUMP .PERM.IT Permit No. 7 Z- v <br /> THIS PERMIT,EXPIRES. `l",YEAR FROM-DATE 'ISSUED ' Date Issued _ Z "�v <br /> (Compl`ete -In�Triplicate) <br /> Application;is3hereby�made,ret' thes;San-fJoaquin.:-Local Health District fora permit to construct <br /> and/or inst4ll the work herein described. Thio application is made incompliance with San%Joaquin <br /> County-Ordinance Naz :1862^aT,d'the.rvRules` and';Re ulations,of the. San Joaquin i.n Local Health District. <br /> �' g q <br /> JOB ADDRESS/LOCATION ��G ��i �/� / p�� -- --- _-- = CENSUS TRACT - <br /> "Phone <br /> RACT - . <br /> ?4a <br /> �Owner!-s. Name:Y� J�/� •, _I it �;,. r ] cw , aPhone j�—7 <br /> �. �,•, <br /> Address /4 tS ? �fi l�D�a.. e9 -. City <br /> Contractor's Name `f lig License # Phone <br /> i � F <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP 'INSTALLATI. ON I / PUMP REPAIR I / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j Cable Tool Dia, of_Well Excavation 'ago <br /> Domestic/private t Drilled Dia. of`w ell Casing <br /> Domestic/public ;_ Driven Gauge of' Casing <br /> Tr'rigation j Gravel Pack Depth of Grout\Seal <br /> Other Rotary Type'-of `Grout <br /> j Other Other Information <br /> I j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump' H.P. <br /> PUMP REPLACEMENT: State Work Done Be 11_4,:�r ,few <br /> PUMP REPAIR: / / State Work Done <br /> . f , <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t � j <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 �iy knowledge and belief. <br /> SIGNED � � TITLE <br /> f F RAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY DATE 7:; 7-7- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECfON <br /> BY DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426. 4/72 1M <br />