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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF761'FTCE USE: .11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j <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 :Wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. stealth District. <br /> i� <br /> JOB ADDRESS LOCATION ,,.�,�,..Gc OG CENSUS TRACT ' <br /> Owner's Name _ T M G fid f N C/2 I D L - Phone UQ9.- RE 4 0 <br /> Address f L� Iy fj�ROel �i4 City S Z/(A/ C-,4 L/1Contractor's Name 'T/Apt,&Np C k,184. / OqJ< D , nse #.26-aPhone Fy>_0t39,[,C <br /> II <br /> TYPE OF WORK (Check) : NEW WELL f DEEPEN/ / RECONDITION f / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ~~�` <br /> 0 th ih <br /> DISTANCE TO NEAREST: SEPTIC TAINK //p ` SEWER LINES PIT PRIVY -.0 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER of <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation gyp- <br /> X Domestic/private Drilled Dia. of Well Casing 67 <br /> Domestic/public IDriven Gauge of Casing /2 <br /> Irrigation Gravel Pack . Depth of Grout Seal D ' <br /> Other � _ Rotary Type of Grout <br /> Other Other Information ;. <br /> Z6S7d1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump *.� --- --- -- H.P. '.:Z C� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: 17 State Work Done ' <br /> ,DF'CTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I' <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 my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information 'is true to thelbest of my knowledge and belief. <br /> SIGNED i� TITLE <br /> ��. '(MNW PLO AN ON REVERSE SIDE) <br /> I� FOR DEPARTMENT USE ONLY <br /> PHASE I 1 -7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: IE <br /> PHASE II GROUT INSPECTION PHASE !U/FINAJ,!U/FININSPECTION <br /> INSPECTION BY INSPECTION BY - DATE <br /> CALL FOR A GROUT IN ECTIO -PRI R •TO GROUTING AL SPECTION. <br /> E H 1426 dfO'�le A °� _ 5/733M j <br />