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SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6782 <br /> APPLICAiiTION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - SQ <br /> THISl• PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / /d <br /> (Complete In Triplicate) <br /> Application is hereby made to Ahe San Joaquin Local Health District fora 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 3736' f - CENSUS TRACT - <br /> Owner's Name Rp 2 /� + [��`1�lr ,���io� C Phone <br /> Address CT20 . 0 1 P- City C_ � <br /> i <br /> j <br /> Contractor's Na License # e 4-- Phone j�6 =-22 <br /> A <br /> _x <br /> TYPE OF WORK (Check): NEW WELL /� -7 W- <br /> RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUNK' REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> y_ Domestic/private I Drilled Dia.- of Well Casing <br /> Domestic/public 'I Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout _ <br /> Tt- <br /> I Other Other Information I <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT. /)C/ State Woxk Done C..0 C)/X �,�..,� �- A14-ik <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL_; Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and the State o€ 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 i <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 kno ed and belief. <br /> SIGNS �/ --" �'- ITLE I <br /> 22 (DRAW PLOT PLAN ON &EVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE A Q 2 <br /> ADDITIONAL COMMENTS: til <br /> PHASE II GROUT INSPECTION PHASA I111FIDAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />