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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,73- .2,G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-4/__F__z5' <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 Joaquin Focal Health District*" <br /> JOB ADDRESS/LOCATION -/_ oda TRACT <br /> Owner's Name � � � �s��".� 2�/,/ Phone <br /> Address City <br /> Contractor's Name ^Vk Well 0 (0/ License # Phone <br /> asc�•z•+ _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL ATION / / PL',MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other ./ <br /> T r:m <br /> DISTANCE TO NEAREST: SEPTIC TANK /Da � SEWER LINES 00 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1p :� CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Glel <br /> x Domestic/private Drilled Dia, of Well Casing ,✓��! <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation x Gravel Pack Depth of Grout Seal, (y a <br /> Other Rotary Type of Grout <br /> Other Other Information c <br /> PUMP INSTALLATION: Contractor A6 We- wia t + "V) � � � � � �C7s�t"))e, 6LV <br /> Type of Pump Mae4lb I H.P. <br /> PUMP REPLACEMENT: State Work Done - <br /> PUMP `tEPAIR: /_7 State Work Done <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 5 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 my knowledge and belief. <br /> SIGNEDA 9j &:9 — <br /> TITLE <br /> (DRAW-PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT. USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -DATE- p z 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION I I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTI DATE -� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br /> �f <br />