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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> S�Or."O FICE 4USE: 1b01 E. Hazelton Ave: , Stockton, Calif. <br /> � _ Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ?e� <br /> 0 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z 7,P',2¢ <br /> (Complete In Triplicate) <br /> Appli , tion is hereby made to the San Joaquin Local Health District for a per it to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .h /- % " • ' _ CENSUS TRACT (3 <br /> Owner's Name T e T U G r- <br /> Phoney�G <br /> Address <br /> ri. / City, 1 GC/f-T-, <br /> Contractor's Name . //(' I�/���__� U ll� U. --_- _ License # 7 Gad_ Phone <br /> TYPE OF WORK (Check):. NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTTALLATION / / PUMP REPAIR �/ PUMP REPLACEMENT IST <br /> h <br /> ' Other L-1 , G� <br /> d DISTANCE TO NEAREST: H SEPTIC TkNK SEWER LINES PIT PRIVY <br /> ! SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER u) <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation �( <br /> Domestic/private --� Drilled Dia. of Well. Casing <br /> Domestic/puki.c Driven Gauge of Casing <br /> Irrigation :_ Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other Other Information Al T <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. Y <br /> UMP REPLACEMENT State Work Done <br /> a I / <br /> PUMP REPAIR: State Work Done <br /> E pFgTRUCTION OF WELL: 1I Well-',Pl:ameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San .Joaquin Local Health District <br /> i and the State ofCaliforriia pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,j_,.will furnish the San Joaquin Local Health District <br /> WELL-DRILLERS, REPORT of .the well and.notify .them before putting the well in use. The above <br /> information-i rue o the b t of my knowledge'and:belief. <br /> SIGNED TITLE A 1� J <br /> (D 'PL PLAN ON-REVERSE SIDE) <br /> FOR DEPARTMENT`USE.-ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `DATEft`�a <br /> ADDITIONAL COES <br /> NTS:-E II GROUT INSPECTION PHASE II NAL SPECTION <br /> INSPECTION BY DATE �. NSPECTION BY TE <br /> CALL FOR A GROUT dNSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />