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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .. e2 Telephone: (209) '466-6781 <br /> �} APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> lTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f Date Issued <br /> I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health lth District for a permit to construct" and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> Cqunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tv -� xyA,� CENSUS TRACT ' <br />� _fL �s ���Y <br /> k- _ <br /> Owner's Name M„M. _ Phone <br /> 10Q 0 <br /> �.�0 fr fiv <br /> Address ., e� D%Qiti �Qv� S70 ae 70 "ter C�- 9.#�� ' City ' <br /> Contractor's Name ,.To O /-I A a~i,, A- o fj C-g License #22Lf�>ZPhone 4 � <br /> TYPE OF WORK (Check). --NEW4MLL. -7,>--I- -DEEPEN,./--7- -RECONDITION /--/ DESTRUCTION _ <br /> PUMP INS ALLATZON PLW REPAIR 'I I PUMP REPLACEMENT /-7 <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 SEWER LINES PI <br /> _ T PRIVY <br /> SEWAGE DISPOSAL FIELD-70 �L CESSP 0I;/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia.., of Well Excavation /t)It <br /> ^ Domestic/private : ! Drilled <br /> _ Dia. of Wel]. Casing 471 <br /> .I}. Domestic/public ' ' I Driven Gauge of Casing. C.,g , <br /> II' Irrigation `.q 'Gravel P�- a k =Depth of-Gfout Seal o <br /> lI Other �-Rotary �,: Type of Grout 059 i <br /> i Other Other Information P Pdpo <br /> x -'— <br /> PUMP INSTALLATION: Contractur <br /> Type of Pump y` 5 -7 r,M. eta7 ip T / �t/S/04er°p 0 .P. <br /> PP! .REPLACEMENT: f-1 State Work Done <br /> PUMP URAIR: / / State Work <br /> ------ <br /> F.4"TRUCTION OF WELL: Well Diamleter Imate Depth <br /> Describe` Material and Procedu .. .... Yet 4 <br /> I i,[ereby agree to comply with all la' r -- <br /> Y re <br /> of the San Joaquin Local Health'District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS I <br /> after completion of my ;wrork on a new well, I will furnish the San Joaquin Local Health District a , <br /> WELL DRILLERS REPORT of .the 4ell and notify them before putting the well in use. The above ' <br /> information?s true to ;the best of my knowledge and belief, <br /> �i 0 M Pr G;h 13 O 0 co ci <br /> SIGNED # TITLE <br /> _ 4' ,. <br /> 2 } (DRAW PLOT PLAN ON REVERSE SIDE .fcr,�7 _ - <br /> } <br /> PHASE I q� FOR DEPARTMENT USE ONLY �a <br /> :APPLICATION ACCEPTED BY <br /> DATE 6 <br /> ADDITIONAL COMMENTS: <br /> INSPECTION BYPHAS II GROUT INSPECT-ION J 'PRASE 'III FINAL INSPECT ION �C� <br /> pp DATErj-2-2 �/ _ INSPECTION BY �, DATE# <br /> CALL FOR A GROUT INSPECTION,-PRIOR TO GROUT NG AND FIN TNS I N. s <br />_ E H 1426 5'. C /72,�. 1 <br />