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FOFi OFFICE USE: <br />6At- 1JAQUIN LUCAL HEALTH DISTRICT <br />1601 Hazelton Ave., Stockton, Cali <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />Permit No. %/,/ <br />7s-aJf,� <br />Date Issued6-75 <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 lations of the San Joaquin Local Health District. <br />AP -61 <br />JOB S/LOCATION -S, CENSUS TRACT <br />Owner's Name <br />Phone <br />Address 04 54:1 <br />/ / City <br />Contractor's Name /G%%J,�%����./� !il/moi License A57ewpf ne9j��1 Zl� <br />E OF WORK (Check): NEW WELL) DEEPEN /-7 RECONDITION ST CTI N <br />PUMP INS ALLATION /�J PUMP REPAIR /� P REP C NT /% <br />Other ./-7 J-' <br />DISTANCE TO NEAREST: <br />INTENDED USE <br />SEPTIC TANK SEWS <br />SEWAGE DISPOS L FIELD <br />PROPERTY LINE// PRIVATE <br />TYPE OF WELL <br />Industrial <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br />UMP INSTALLATION: Contractor <br />Type of Pu <br />PUMP REPLACEMENT: <br />PUMP .REPAIR: <br />NESTRUCTION OF WELL: <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />R DINES /Z)/ J - <br />—�- CESSPOOL <br />DOMESTIC WELL <br />State Work Done <br />State Work Done <br />PIT P IVY <br />SE P GE PAT � tZ- OTHER <br />WfPUBIC DOMESTIC WELL <br />RUC ION SPECIFICATIONS <br />a,� o 611/ Ex avation _ <br />ia.�d ell Ca�ing <br />Ga ge Casin <br />Depth Grout Seal <br />Typ of out <br />Other In rmat on <br />Surface Seal In talled B : <br />i <br />Well Diameter <br />Describe Material and Procedure <br />H. P. <br />Approximate Depth <br />hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />IOR TO GROUTING AND A FINAL INSPECTIO /✓" r" <br />IGNED I -(-f- TITLE /-)! ii,.t� <br />P 0 PL ON REVERSE SIDE <br />FOR DEPARTMENT USE ONLY <br />SE I <br />PLICATION ACCEPTED BY <br />DITIONAL COMMENTS: <br />P SE II GROUT INSPECTION <br />SPECTION BY tic yc s DATE <br />z �t. t<< <br />E 11 1426;1-74 <br />DATE <br />' PHASE III FINAL INSPECTIO <br />INSPECTION BY /a:z. DATE <br />,r � <br />�-l. C. L h/75 <br />