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SAN JOAQUIN LOCAL HEALTR DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> AOR OFFICE USE: <br /> l Telephone: (209) 466-6781 ' _P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L3 -- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED . Date Issued 3--_14-73 r <br /> (Cornp.lete In Triplicate) dp �f- c)-70 -0/ <br /> t0 the San Joaquin Local. Health District for a permit to construct <br /> Application is hereby made <br /> and/or install the work herein described. This lotionsapplicaof the made <br /> ueJoaquinpLocaleHealthSDistrict- <br /> County Ordinance No. 1862 and the Rules and Regulations of i <br /> CENSUS TRACT <br /> "JOB ADDRESS/LOCATION <br /> Phonejr!:p/ <br /> �� <br /> Owner's Name ' <br /> � <br /> City <br /> Address <br /> ' ,, � •�r �a License ���=_L2�Phone <br /> Contractor's Name <br /> RECONDITION /-T DESTRUCTION 7 <br /> ! TYPE OF WORK (Check). NEW WELL // DEEFEN '/p� PAI I I, puffPLACE 4ENT <br /> PUMP INSTALLATION / T <br /> Other / / s f <br /> S LINES PIT PRIVY O HER J <br /> SEPTIC TANK , CESSPOOL/ BKPAGE IT <br /> SEWAGE DISPOSAL FIELD / <br /> DISTANCE TO NEAREST: _moi- <br /> � :P l CONSTRU AT <br /> ION SPECIFICIONS <br /> INTENDED USE PE OF ELL - " rn <br /> � Cable Tool Dia. of Well Excavation <br /> Industrial Drilled Dia. of Well Casing <br /> Domestic/private ----~ Driven Gauge of Casing ' <br /> Domestic/public Gravel Pack Depth of Grout Seal ' <br /> Irrigation ;I `--"- Rotary Type of Grout <br /> Other Other Other Information ,• i <br /> Contractor � - R'P' <br /> PUMP II3STALLXT iON: Type of Pump <br /> PUMP REPLACEMENT: / State Work Done --�c <br /> PUMP REPAIR: /-7 State Work Done <br /> Approximate Depth <br /> C <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Health District. <br /> uin Local <br /> W construction- Within "FIFTEEN ISYS <br /> I hereby agree to comply with all laws and reg ul� 8�ig f the San Joaquin Local gealth District a <br /> and the State of California Pertaining to or reg <br /> I will furnish the San <br /> well is use. The above <br /> after completion of my work on a new well, the <br /> before Putting <br /> WELL DRILLERS REPORT of the well and notify <br /> knowledge and belief. <br /> information i true to the`b�t of ary TITLE <br /> SE SIDE <br /> SIGNED W PLOT PLAN ON RESER <br /> FOR DEPARTMENT USE ONLY <br /> DATE �r 3 <br /> PHASE I <br /> APPLICATION ACCEPTED BY PHASE I -FINAL INSPE ION <br /> ADDITIONAL COMMENTS: INSPECTION DATE <br /> PHASE II GROG DATE INSPECTION BY �Z- <br /> INSPECTION BY GROUTING "FINAL INSPECTION�r 4/72 ]M <br /> � ;.� <br /> CALL FOR A GROUT INSPECTIOII PRIOR TO <br /> E H 1426 <br />