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G� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 15�3 -2q/p .E <br /> THIS "PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <br /> s (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 /> /;Z- 7 ,.T-y I z , SUS TRACT <br /> JOE ADDRESS/LOCATION Uri <br /> Owner's Name W 2� a Phone <br /> Address 3 SS 3 S' c�cp.• - City. <br /> r <br /> Contractor°s Name A i R � � - License #/ Phone <br /> I <br /> TYPE OF WORK (Check) : NEW WELL /, DEEPEN"`/_77-`'RECONDYITION TT-- DESTRI]CT7 _ r <br /> PUMP INSTALLATION &7/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> p <br /> Other- <br /> DISTANCE <br /> therDISTANCE TO NEAREST: SEPTIC TANK 6V SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE -OF WELL - CONSTRUCTION SPECIFICATIONS <br /> _ Industrial „ . — .-i- - .A ...Cab•1e�Tool- - - Dia.-- of-We-11=Excavation" "/ --- <br /> X Domestic/private Drilled, Dia. of Well Casing <br /> Domestic/public Driven 41 Gauge of Casing fd2 <br /> r Irrigation '` Gravel Pack' ' Depth of Grout Seal <br /> r Other ' Rotary Type of Grout. CAIA�� ' <br /> Other Other Information � C�,......p`f�G., , <br /> PUMP INSTALLATION:' Contractor <br /> { <br /> Type , Pump _.f H.P. <br /> ! i <br /> PUMP REPLACEMENT: I I 'S tate..Work Done <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 JoaquinLocalHealth District <br /> and the State of Californiaipertaining to or regulating well construction. Within FIFTEEN DAYS <br /> k 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 /> r SIGNED s TITLE <br /> (MW PL PLAN ON REVERSE SIDE3 <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I _ .-DATE 11 - <br /> APPLICATION ACCEPTED $Y, <br /> ADDITIONAL COMMENTS: <br /> -- PHASE II GROUTrINSPECTION - " PHASE II_ FINAL INSPECTION <br /> E INSPECTION BY ,DATE INSPECTION BY DATE <br /> p <br /> CALL 'FOR A GROUT INSPECTION PRIOR TO GROUTING. AND FINAL INSPECTION. <br /> 4 F H 1426 7/72 1M <br />