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��- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fFOL. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1,r12_S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a7L/ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z S / '�b 2 U LLL" Ave CENSUS TRACT <br /> Owner's Name 1 w x. s Ilk Phone Z oo <br /> Address 2.5152 (ALL ER <br /> City Esc L'a <br /> Contractor's Name-wt( oal t 1NL License #2/o_W'2_ PhoneS2 - <br /> 92-71 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -/—/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION !�! PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_/ — <br /> { <br /> DISTANCE�TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSALFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f . <br /> INTENDED USE TYPE OF WELL N <br /> ENDED USE CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing " <br /> Irrigation g Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �[ L� g, e(�� , a. &c <br /> Type of Pump 7 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `ZEPAIR: <br /> / / State Work Dane <br /> ,DFgTRUCTION 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 /> informatipn is true to the best of my knowledge and belief. <br /> SIGNED �( ,� ,,�� <br /> _ TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SID- <br /> _c_})------------------------- <br /> L� <br /> FOR EPARTMENT USE ONLY <br /> PEASE I <br /> APPLICATION ACCEPTED B DATE °Z -z 54 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E �XFINAL_INSPECTION <br /> INSPECTION, BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Ca <br /> E H 1426 1�/71-iu <br />