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{ <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Z1601 E. Hazelton"Ave.,, Stockton, Calif. E" <br /> ��. Telephone (20 9) 466-6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> --177 P <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 Joaquid <br /> County'�Ordi.nance No. 1862`andthe 'Rules and Regulations of the San Joaquin Local. Health District. <br /> . r <br /> JOB ADbRESS/LOCATION _ ���dcti2 / (, - _ { '� CENSUS. TRACT <br /> Owner's Name Phone <br /> r� <br /> Address _- _a//00 e!5,�rvy c�G 2}G .S _� city <br /> Contractor's Name p �� . ' _ License Y00 Phone <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN /� RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / J PUMP REPLACEMENT /_7 <br /> Other /. / <br /> f— <br /> F <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 /> { <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X'^ Rotary Type of Groutv�C7, <br /> �R .Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP REPAIR: / / State Work Done <br /> I <br />,PESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> I � E <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 a new-well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of a well and notify them before putting the well in use. The above i <br /> information is ,true, the best of my knowledge and belief. 9; <br /> SIGNED • TITLE <br /> IM RAW PLOT FLAN ON REVERSE SIDE <br /> �p FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL AL COMMENTS: -/- ` .ern..a c.✓ 9.'�s: j <br /> PHASE II GROUT 114SPECTION PHASI-IIIFIRW INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> I` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT QB <br /> E H1426 7/72 1M <br /> M <br />