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l P . <br /> SAN JOAQUIN LOCAL i.TALTH;DZSTRICT <br /> FOR `O�iFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z-Z-' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED , Date Issued q-2 5-'71/ <br /> (Complete In Triplicate) <br /> Application is h eby made to the 'San Joaquin Local Health District for a permit to construct r <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 /> / 3 <br /> JOB ADDRESS/LOCATION 21?Z10 L-DD/Y11.S_ O^ CENSUS TRACT <br /> Owner's Namett 1. �. LAKaT-sn5 Phone ' (a.3 -,5309 f <br /> Address LOOMi/:5_.RD. - - --- -- - City ' .STaCLrQ6l <br /> Contractor s Name <br /> HE'NNfNGS EROS. DRILLING Co., INC- <br /> Contractor License # b3Phone $"20-S(g y3 <br /> J <br /> MOpESTOCALIF— � . d <br /> TYPE_ OF WORK(Che k) CF <br /> : - NEW CA RMN71 RECONDIN /_7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK r ' SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER•,NtL&,eP4j 0_ <br /> 'T7�iAl*. � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> — <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 50� <br /> Other Rotary Type of Grout _ 86AZZ NIZE _ O <br /> Other Other Information ' <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump _ _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />-.PEST-RUC-T--1-ON-0E-WELL;--- �We17:-Diameter - Approximate Depth V <br /> Describe Material and Procedure F <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 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 /> SIGNED , /, .,Vfr TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / " 72-_ , <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTIO PH <br /> A <br /> S <br /> III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRI; TO ROUTING AND FINAL INSPECTIO . <br /> E H 1426 l 4/72 1M <br />