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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y- yy <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 iPaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :2 9001P S CENSUS TRACT <br /> Owner's Name ZA at Ce N18® !z F_ Phone 4I/5`- 5`y 7 6 4f7 a <br /> Address /DOrx A . 4z A R 1 5 _W V _ _ - City i Aff e-AAla C A 4.1^ <br /> Contractor's Name cry-i.G� -�f_,. ���.�G License # 7-G1'761 Phone 464pk.'?2 <br /> i <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/ RECONDITION / 7 <br /> AL _/ DESTRUCTION / <br /> PUMP INSTALLATION /�/ _PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> E <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled ._„Dia. of Well Casing Q <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal, <br /> Other Rotary a Type of Grout . <br /> Other Other Information <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> -- <br /> Type of Pump 5.�.s�� _ H.P. Sp <br /> PUMP REPLACEMENT: / / State Work Done �.� <br /> PUMP UPAIR: / / State Work Done <br /> ,DRCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 Hearth 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 ,.� TLEu-�e� '��." <br /> (DRAW PLOT AN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO I EC I PHASE III/FINA� INRECTION <br /> INSPECTION BY DXTE INSPECTION BY � TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F. 9 IL96 K/711v / . <br />