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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OFI=ICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,y7 Q 1Gc� <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 Sant Joaquin <br /> County. Ordinance No..:1862 and the Rules and Regulations. of the San Joaquin Local Health District. ' <br /> 44r <br /> g` r CENSUS TRACT <br /> JOB ADDRESS/LOCATION �r`o�rf <br /> .ri/�ii�(xi �l e `07i t r"J � Phone <br /> owner's Name -• -- <br /> .�'id f-'/-B �'�` <br /> Address F ' City <br /> / License IIVP;&�hone <br /> Contractor's Name . �'� / f/ .S.:e1�l , <br /> TYPE OF WORK: (Check) : NEW WELL /��'/ DEEPEN 'k_-;? RECONDITIONP /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / f PL'NIP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial L-,-- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. of Well Casing a' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout i, '0 ivr • k <br /> Other other Information <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pump H.P. <br /> PUMP •REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR. / / State Work Done <br /> Approximate Depth <br /> AFr-TRUCTION OF WELL. Well Diameter Pp P <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. Within FIFTEEN DAYS <br /> after completion of., <br /> my,york on a new well, I will furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS,. REPOR'F' of .the well 'and b <br /> nd notify them efore putting the well in use. The above <br /> informaLidn'"is true to the*best of my knowledge and belief. <br /> r,= <br /> SIGNED = Z. <br /> TITLE <br /> 177 (DRAW PLOT PLAN ON .-REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .�-7��7' <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TT GROUT INSPECTION P1 NAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE _7, <br /> 4i <br /> CALL FOR A-GROUT -INSPECTION WTO. ROUTING:AND FINAL INSPECTION. <br /> W U IA9A _ 5/731M <br />