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I aw 4104 4- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T3,//a kJ <br /> 7-s-71.1-04 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 an he ijes, ano Regulations pf the San Joaquin Local Health District. <br /> JOB MDRESS LOCATION [" ,q /fj��f 99 z CENSUS TRACT <br /> Owner's Nance �D �Irc„� lmiP� �►� 4 IT �__--- Phone <br /> Address J y G�/'P1 City _.. <br /> i <br /> Contractor's Name I� ov alt i z 5 I " G Licens M Phonef - Z 10 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INST TION /3d PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> i Other / / \ <br /> d <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE_.DISPO AL-F-IELD_�-CE SPOOL%EEPA-GE-a-PI-T-- �—OTHER— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> IndustrialY..Cable-.T-ool—Di-a_-of-Wel-l-Excavation -- <br /> Domestic/private X, Drilled, ' ' Dia. of `Well Casing 4- � <br /> Domestic/public 1 Driven Gauge of Casing / 6N <br /> Irrigation 1 1. Gravel Pack ' ; Depth of Grout Seal <br /> Other if Rotary Type of Grout <br /> I!' ; Other Other Information <br /> PUMP INSTALLATION: Contractor2 S'fi -S <br /> Type,,of_fPump H.P. _ <br /> _ t <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP REPAIR: J / State Work Done <br /> ,DESTRUCTION OF WELL. Well Diameter C 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 pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of mytwork on•-a-new-we`ll; I wrill furnish-the San Joaquin Local--ffealth I}istrict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is tr to. the best of my knowledge and belief. <br /> SIGNED I� TITLE &ke14fV <br /> �I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSnCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY * e3 DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPE ON-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ,�. 7/72 1M <br />