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�-�• SAN JOAQUIN LOCAL }MALTH DISTRICT <br /> 1601 E. Hazelton Ave, <br /> Stockton, Calif. <br /> -- Telephone: (209) 666-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU`tP FF.R`tIT Permit <br /> THIS PER2'IT EXPIRES 1 TEAR FROM DATZ ISSUED <br /> Cate Its [ .3 <br /> Application is hereby made to the San Joaquin inLocalIn rHealthtDistrict fot a -L�'►J <br /> and/or install the work herein described. - :his application t.ritf� s �Son � <br /> County Ordinance No. 1862 and the Rules la Wade in cos,liac�caand Regulationa of the San Joaquin Local <br /> JOB ADDRESS/LOCATION �I • <br /> r D LI /ee amus Tma <br /> Owner's Name �— <br /> Pbon4�3 <br /> Address �• 9�rt t <br /> Citi <br /> Contractor's Nage �� � <br /> Licenaa <br /> TYPE OF WORX (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION I? <br /> PU 3 It:STP,LL,ITION PL?SP REPAIR /? PUYP RBFLACE m I'7 <br /> Other / / <br /> DISTANCE TG ;IE.'BEST; SEPTIC T! 1 <br /> SEVER LINES t^IT PRIVY <br /> SEWAGE DISP SAL F:ELD CESSPOOL/SEEPACE PIT <br /> OTKER <br /> INTENDZD USE TYPE OF 'JELL <br /> Industrial CONSTRETION SPECIFICATION <br /> Cable Tool D;a, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack <br /> Other Depth of Grout Seal <br /> Rotary i}pe of Grout <br /> Other Other Information <br /> r <br /> PL?P INSTALLATION: Contractor Ve- �I ♦� <br /> Type of Pump , H.P. <br /> PJ"p REPLACE,,,aNT: J / State Work Done <br /> Pl7'tP 'tEPAZR: State Work Done <br /> D'r-TRUCTION OF WELL: Well Dicmeter <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 /> 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 DRI ERS REPORT of the well and notify them before putting the well in use. The above <br /> informa on is u to the best of my knowledge and belief. <br /> SIGNED TITLEQ <br /> - DR ,I PLOT PLAN ON REVERSE SIDE) <br /> P4iASF I FOR DEPART24.\'T USE ONLY <br /> A?eLICATION ACCHPTED BY <br /> A.DDITI0\,1L CO. _NTS: DATE I <br /> L- <br /> ?i_S: II <br /> G- <br /> ROUT INSii:C:IO'` PHASE I-I FINAL INSPECTION <br /> INSPECTION BY ter- DATE •_ J`- INSPECTION BY - 11' <br /> DATE _ <br /> CALL FGR A GROUT INSPECTION PRiJ.f O GROUTING AND FINAL INSPECTION. <br /> 5/73L,i <br />