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i �U <br /> V JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR OFFICE USE: 1601'E. Hazelton Ave. , Stockton, Calf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -'5-2j.zf4 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION dggQ AQ,W, &I LZ 014 //-f _ , CENSUS TRACT S / <br /> Owner's Name Phone <i 3t- <br /> Address <br /> Address ° Q2 ` n9 �/n4 City <br /> Contractor's Name 9{tQ , amu) License N jjoPZ Phone r*6 —3 <br /> TYPE OF WORK (Check) : NEW WELL Z7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P.IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q.J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> Industrial Cable Tool Dia, of Well Excavation A <br /> Y Domestic/prigate Drilled Dia. of Well Casing >Z'��•• f ti' t� <br /> �Y Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 6-2- N <br /> Other Rotary Type of Grout rarcn.� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter e, Ati& Approximate Depth <br /> Describe Material and Procedure <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 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 /> SIGNED � g1as.J TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> tZ" 14 GROUT INSPECTION I NAL INSPECTIO <br /> INSPECTION BY DATE 'Z`(-73 INSP N DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />