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f <br /> T 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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. 1.862 and the Rules and Regulations of the San Joaquin LocalIleal.th aCDistrict. <br /> ,� <br /> JOB ADDRESS/iATION / , ,�1?r� �1 CENSUS TRACT <br /> Owner's Name dnk Phoney&, - , 3 <br /> Address �r !Rk City ' <br /> Contractnr's Name <br /> License ��(S7 Phoney <br /> TYPE OF WORK (Check): NEW WELL/ J DEEPEN '/-7 RECONDITION f_1 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT ` <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of'Well Excavatibn <br /> Domestic/private Drilled Dia. ofiWell Casing <br /> I' Domestic/public t Driven Gauge of Casing\. <br /> f Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> �r <br />+ PUMP INSTALLATION: Contractorm <br /> r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i / State Work Done <br /> E <br /> 3 PUMP UPAIR: State Work Done <br /> 3 DF-,TRUCTION OF WELL: Well. Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> d e <br /> Ihereby agree to coinplyiwith 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 RE of the well and notify them before putting the well use. The above <br /> information is rue `tokthe b t of 'y knowledge and belief. <br /> i} <br /> SIGNED TITLE <br /> PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />"€ PHASE I <br /> i} APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL =MNTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B , IV4 DATE c <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. A� <br /> - V TT ILIA `597 31M <br />