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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'or- <br /> OFFICE USE: 1601 E. Hazelton""Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�7V_.23_2Id <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-8r 7 <br /> (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to :con.struct <br /> and/or install, the work herein described. ' This application is wade in compliance witch San Joaquin <br /> County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> � f SlCENSi3S TRACTi` �� f <br /> Owner's Name Phone «. 1 <br /> Address V� City . . <br /> Contractor's Name ­60VIVEI!�,'_ <br /> License # Phoney <br /> -S <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> F PUMP INSTALLATION- / / PUMP . REPLACEMENT/7' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK '�tSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 'F,IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE - TYPE OF Dta. of WCONSTRUCTION SPECIFICATIONS <br /> ndustrial <br /> Excavation <br /> r - Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other "Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work DoneQ <br /> PUMP`tEPAIR:, -- ­1/.- C7.St ate Work Done ' <br /> ,DF.RTRUCTION OF WELL: Well , <br /> ' — — Wll Di ����.H��6� ,._4;�; Approximate Depth 150 � <br /> Describe Material and Procedure <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. <br /> Within FIFTEEN DAYS <br /> after completion of my work�c a new well, I will _furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT of .the Ewell, 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 " <br /> TITLE <br /> (DRAW PLOT 2tn 02N REVERSE SIDE) <br /> YEARVIENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE DATE <br /> -71 <br /> ADDITIONAL CO <br /> T I G T INSPECT N I IXI FA AL INSPEG N <br /> INSPECTION ATE �� INSPECTION DATE <br /> - - CALL FOR A 'GROUT INSPECTION PRIOR T GROUTING AND FINAL INSPECTION. <br /> E H _1426 <br />