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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (2.0.9) 466=6781 Permit -No. <br /> APPLICATION FOR WELL-,CONSTRi3CTI0N OR PUMP PERMIT <br /> y� Date, Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE"ISSUED i. <br /> (Complete In Triplicates <br /> A lieation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> PP <br /> and/or install the work herein described. This applicsto nthe San eJoaqu nin pLocaleHealth with SDistrictan in <br /> County Ordinance No.. 1862 and the Rules and Regulationy <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ® y <br /> Phone <br /> Owner's Name <br /> city <br /> Address � a ,..4�` - .. , <br /> `` Phone 3 <br /> License # �'� <br /> Contractor's Name _ ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION_/�- 'HEST'RUCTION- / T r _ r <br /> r. PUMP INSTALLATION �I -PUMP REPAIR / PUMP' REPL4CEMENT /� � <br /> Other.. / / <br /> l h <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> SEWAGE DISP:Q�,AlbFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,''%,- ' <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF a, ,, <br /> Industrial Cable T� ; _.. Dia. of We11 Excavation oZ- <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven r,+ Gauge of .Casing <br /> Domestic/public th of Grout Seal <br /> 4 Irrigation Gravel .Back-.---__,De p <br /> f Rotary Tyke of Grout ' <br /> Other Other Otherf Ci <br /> J <br /> i 1 <br /> PUMP INSTALLATION: ". Contr —:S' -,H.P. <br /> Type f <br /> 'rte I <br /> e <br /> PUMP REPLACEMENT: / State To71c9one / <br /> PUMP REPAIR: / , tate tWor boi?e <br /> fi °' •"+ a+! .� � '=Ap.proxmat6-,Dep <br /> th_ - - - <br /> ;pESTRUCTION"OF WEL'L-r ":WeI3�333amete "s_ <br /> ,Desex-i.be;Material and Procedure F <br /> r 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 <br /> cSantJoaquinuction•L calhHealth ifi TDistrict a <br /> after completion of my work an a nein well, I will g r`�1e above <br /> WELL DRILLERS REPORT of th well and notify them before puttin the well in usg( , <br /> f information is true to$ the= esti-)of my knowledge and belief. <br /> r- <br /> TITL /I 4 <br /> SIGNED . .. " <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J-...�,.-- .� DATE,, <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASEIII/FINAL INSPECTION <br /> " PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY /` DATE <br /> CALL FOR„A• GROUT INSPECTION PRIOR TO. GROUTING AND FINAL INSPECTION. 4./72 IM <br /> E H 1426 �` <br />