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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t,0£_'OFIICL SE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 4-L5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _If�L3 <br /> (Complete In Triplicate) r rJ = 2co -- t-3t-' construct <br /> Application is hereby 7made to the San JoaquinLocal Health District for a p <br /> and/or install the wont hereindescribed. , This application is wade in compliance with San Joaquin <br /> County Ordinance M0,6.1862 and the Rules and Regulations of the San uin Local: 11eal.th District. <br /> 3 A/- �6at r l � v CENSUS TRACT S�� <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> owner's Name <br /> City , 3 <br /> Address <br /> t License # ° hone <br /> Contractor's Name <br /> G TYPE OF WORK (Check) ; <br /> NEW WELL / DEEPEN / ] RECONDITION / / DESTRUCTION 1rT <br /> PUMP REPLACEMENT <br /> PUMP INSTALLATION / / PUREPAIR { / <br /> MP I� <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TA-K R LINES IIT PRIVY <br /> SEWAGE DISPOS L LD CESS L/SEEPAGE PIT OTHER Z <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL CON5TRUGTION - <br /> Cable Tool Dia. of Well Excavation m <br /> Industrial , <br />► � Domestic/private Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/public Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Other Rotary Type of Grout , <br /> -- _ Other Other Information <br /> PUS Contractor INSTALLATION: H.P. <br /> 4 Type of Pump <br /> PUMP REPLACEMENT: ] State Work Done - - <br /> PUMP 'UuPAIR: / / State Work Done <br /> DFGTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> f I hereby agree to comply with all laws and regultions of the. San Joaquin Local Health District <br /> a <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 rue to the bes. of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE p " - - <br /> APPLICATION ACCEPTED .BY - <br /> ADDITIONAL COMMENTS: PHASE II /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BYDATE <br /> INSPECTION BY DATE -�9 "7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. /7 <br />