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16 <br /> FOR OFFICE USE: SAN JOAQUIN LOCAL 11EALTH DISTRICT COPY <br /> 1601E, 9azeltau Ave., Stockton, Calif. FILE <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 76-�97p <br /> f J <br /> i= <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ApPlication is hereby made to the San(Joaaqquin Local Health District forarmit to construct <br /> and/or install the work herein described. <br /> Pe ' <br /> with Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations tofnthe Is SaneJde Joaquin LocaleHeal hDistricttt . <br /> 1 a <br /> JOB ADDRESS/LOCATION / , CENSUS TRACT ; <br /> ... . <br /> Owner's xaL-.., <br /> Phone <br /> Address /7 <br /> City e_ O t <br />�. Contractor's Name .;0n Sca-Ir"in Paimp Co. <br /> ;- License / � Phone <br /> r <br /> TYPE OF WORK (Check)-. NEW WELL / W DEEPEN 1't , <br /> RBDONDITION /_7 DESTRUCTION /"r I <br /> .- P;!i� INSTALLATION /� !per REPAIR L� PUMP REPLACEMENT <br /> Other /7 - <br /> A <br /> 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Y <br />�, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT~' OTHER <br /> r <br /> SSD USE <br />? TYPE OF .WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - 0184 of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing W ' <br /> Domestic/public <br /> Irrigation Driven Cause of Casing <br /> pp,11 �r <br /> Gravel Pack Depth of Grout Seal <br /> Other Rotary <br /> -_•�------ xype of Grout -" <br /> Other -- _ Other Information <br /> PUMP INSTALLATION¢ <br />�h Contractor <br /> Type of Pump H.P. <br /> Pi�.REPLACEMENT: /P."State Work Done <br /> fe- <br />�. PUMPREPAIR: <br /> - /7 State Work Done � <br />¢rY r <br /> E:'TRUCTION OF WELL: Well Diameter <br /> s <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4^ <br /> ` and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my wofx 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 ue11 in use. The above <br /> Information is true to the beat of my knowledge and belief. <br /> SIGNED �� p Son Jooquin Pump Co. <br /> { Y=— TITLE (Mvilran of Son Joanvin$41p+ur Cod <br /> DRAW PIAT PLAN ON REVERSE SIDE aeru:.^: o <br /> PHASE I <br /> FOR DEPARTMEI�t: USE ONLY �` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — — <br /> PHASE II GROUT INSPECTION PHAS I F NAL INSPECTION <br /> INSPECTION 8Y _ DATE INSPECTION BY DATB 40 G <br /> I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1N <br /> `�e <br />