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Owner's Name Pe Aims 1,1 libor <br />Address City rAt1".")7.7e9 6736 N. Pesx)-/ fed <br />OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br />CONSTRUCTION SPECIFICATIONS <br />fr Cable Tool Dia. of Well Excavation 41? <br />TYPE OF WELL <br />Contractor \01411),1t \Akil <br />Type of Pump <br />PUMP REPLACEMENT: / / State Work Done <br />SIGNED e2, fe/._iorte6 TITLE <br />(DRAW PLOT PLAN ON REVERSE SIDE) <br />7 DATE <br />SE I <br />LIGATION ACCEPTED BY <br />ADDITIONAL COMNENTS: <br />FOI. OFFICE USE: <br />/ z elig SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />\ <br />PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )20-,/,34) <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date <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 /111.Vpi CENSUS TRACT <br />Issued )-2?---246' <br />r. , <br />Phone 3 ) 72 <br />INTENDED USE <br />Industrial <br />-* Domestic/private <br /> Domestic/public <br /> Irrigation <br />Other <br />Drilled Din, of Well Casing <br />Driven Gauge of Casing 2a... <br />Gravel Pack Depth of Grout Seal 5-e5 <br />Rotary Type of Grout <br />FOR DEPARTMENT USE ONLY <br />INSPECTION BY PHASE <br /> GROUT INSPECTION <br /> DATE Ap / 725- INSPECTION BY <br />PHASE I /FIk.6 INSPECT <br />44052117417 DATE ( <br />CALL FOR FOR A GROUT IN diON PRIOR TO GROUTING AND FINAL INSPECTION <br />E H 1426 <br />PUMP INSTALLATION: <br />H.P. <br />Other Other Other Information