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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 'Permit No. 7,2 T/.pl,o <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Y�, Fd 0 ".� CENSUS TRACT <br /> Owner's NamePhone z 5�1 <br /> OIL <br /> Address " ® 2 City <br /> Contractor's Name *jrrac, c E r License ���_ s � Phone <br /> I <br /> TYPE OF WORK (Check); NEW WELL /_7 DEEPEN RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <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 6` <br /> Domestic/public Driven Gauge of Casing N <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> - - S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter 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 i <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 true to the best of my knowledge and belief. <br /> SIGNED : fJ � ' _ <br /> "� ��� '�- _ �•�..�.v�-cam TITLE �� G __ <br /> (DRAW P OTPLAN ON REVERSE SIDE . -- <br /> FOR DEPART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .�, DATE tjZ Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F1SLU INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR.A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. rt <br /> 7/72 1M <br />