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r' <br /> COPY <br /> SAN JOAQUIN LOCAL HFALTH DISTRICT <br /> 3. I Ot. Oc!It li I1SF. � <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> rt . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> } THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-30-zr- <br /> (Complete In Triplicate) ' <br /> ` = ,Application is hereby ;jade to the San Joaquin Local Health District for a permit to construct <br /> a:tid/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:; :.7-e;. <br /> JOB ADDRESS/LOCATION � J�� Com/ l\-) �!y✓L� �.*C. CENSUS TRACT <br /> v Owner's Name L. f V 1' � � �S _ Phone, <br /> '� <br /> } Address d •C�(�• ��/�J N /�-�`L Citygt c) <t:1U76Aj <br /> - --- --- — <br /> F: - Contractor's Name .j�UM S License / e"1�C���r r fir ' <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /� DESTRUCTION A, <br /> * PMP INST <br /> UALLATION / J PUMP REPAIR <br /> REPLACEMENT <br /> _ / / PUMP <br /> a. Other <br /> DISTANCE TO R'1:AREST: SEPTIC TANK SEWER LINES PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Par <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia, of Well Excavation <br /> ° Domestic/private Drilled Dia. of Well Casing tr <br /> Domstic/public Driven Gauge of Casing <br /> # 4 Irrigation Gravel Pack Depth of Grout Seal :t <br /> Other Rotary Type of Grout <br /> Other Other Information a ` r <br /> PUr-T INSTALLATION: Contractor <br /> ' ? Type of Pump L P;.P. .. ,} <br /> x .z PLi' R],PTACEA�NT: / State Work boneG J ! J u <br /> PUMP 'REPAIR: / / State Work Done <br /> DF<TRUCTION OF WELL: Well Diameter Approximate--Depth'° x <br /> t Describe Material and Procedure <br /> <:.a SiS,4. c tcF <br /> 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District, .' v <br /> and the State California pertaining to or regulating construction. Within FIFTEEN DAY&,'" <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District.'a. , '_ <br /> WF,LL DRILLERS REPORT of the well. and notify them before g <br /> y puffin the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> f <br /> SIGNED TITLE f� '> <br /> DRAW PLOT PLAN ON REVERSE SIDE ' rs:` <br /> F " } FOR DEPARTMENT USE ONLY <br /> x PIiASE I 0/^ <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL CO:=NTS: <br /> ,;.. PIL,bb I' ,C QUT INSPECTION PHASE III/FINAL INSPECT12N � <br /> INSPECTION BY DATE INSPECTION BY ' <br /> n'a <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> Z it 1426 - 5/731M <br /> t:•a; k:fyry_ r <br />