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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t F'OF-�OF`FICE USE: 5; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUPPP PERMIT Permit No. 1 3-30_.�_e <br /> G THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued 4-L�- 3 <br /> (Complete In Triplicate) <br /> ' Application is hereby rade to the San.Joaquin Local Health District for a permit to constl:uct <br /> and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rulers-- and Regulations of the San Joaquin Local Ileal.th District. <br /> JOB ADDRESS/LOCAT ON +� a ", eke 4 CENSUS .TRACT <br /> r / Phone <br /> owner's Name *� - <br /> Address „ 'off°. t kCit !',�' f► ` <br /> ,,. sets! Phone <br /> � . <br /> . y. r c;. ..._.License " . <br /> Contractor's-Name <br /> y: -1-1 <br /> � <br /> kFt TYPE_ OF WORK (Check) : ;, NEW WELL _I DEEP N /,/ RECONDITION / DESTRUCTION <br /> I� REP / <br /> P3MP�INSTAT .A IQN JPb'I�' REPAIR PUMP IT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK T14d SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD" — CESSPOOL"/SEEPAGE PIT OTHER <br /> r' C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIS&E ONS <br /> Industrial Cable Tool Dia. of Well 'Excavation` j# + <br /> l' `Domestie/private Drilled Dia. Yof Well Casing n <br /> Domestic/public, Driven r Gauge of Casing;.;`- '". _. <br /> Irrigation 'r Gravel: Pack Depth of Grout Seal.,.- <br /> Other <br /> ealeOther Rotary____ _,_4. ,Type of Grout <br /> Other <br /> Other Information <br /> V, <br /> f PUMP INSTALLATION. Contractor �" ""' <br /> `. <br /> Type of Pump z TE H.P. . <br /> PUMP REPLACEMENT:' / / State Work Done ' <br /> PUMP.'tEPAIR: ��� / /. .State nWork Done �- <br /> I}RRTRUCTIQN OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 Sai:i­Joaquin Local Health District a <br /> WELL DRILLERS REPORT'of .the well and notify them before putting the well in use. The above <br /> t information is true to the best of my knowledge and belief. : } <br /> SIGNED . ' ,"' TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> a, APPLICATION ACCEPTED .BY <br /> DATE- � II3•J7 <br /> ADDITIONAL CONTENTS:i . _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / 7.3__ INSPECTION BY + DATE J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. "4+ <br /> F T I L 7 6 x- 5 7x31M <br />