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JOAQ:; I ;, LOCAL HEALTH DISTRIC <br /> FOE OFFICF USE: 160�1'F.. Hazelton Ave. , Stockton, Cal'el'. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V;.?e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T-/6-7tf <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local IIealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f �l - y . L �� 7' <br /> .�3;3�� ^/16{J��i _ _ -.�i�rci �5�vi : sc� va r ry'c ro' r.�t..ENSUS TRACT <br /> Owner's Namer i n�CIYI 6,-97 (L Phone p SS5 - 7 717 <br /> --- -� LL <br /> AddressContractor's Name Name dat— 7 //)/D ie <br /> �57, _RC2%��•e <br /> 3.732,0 <br /> TYPE OF WORK (Check) : /� `� r � 7 <br /> DISTANCE TO NEAREST-_S (l <br /> XER tj <br /> P ELL <br /> INTENDED USE - IONS 1z <br /> Industrial <br /> Domestic/private <br /> Domestic/public <br /> Irrigation <br /> Cathodic Protection _V nocary y},� <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 3 6 7X <br /> PUMP .REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND INAL IN CT <br /> SIGNED G- - .�. :{-> �, ,. TITLE �' <br /> (DRAW LOT PLAN ON REVERSE SIDE) <br /> OR DEP T USE ONLY <br /> PHASE I / 74/ <br /> APPLICATION ACCEPTED ATE -7- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INSP .ECTION7 <br /> INSPECTION BY DATE INSPECT I / NAL DATE / <br /> E H 1426 Rev. 1-74 1 -7i, o,, <br />