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D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3Z�-L5 W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'1 3 <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 /> ,70s ADDRESS/LOCATION <br /> Z1 Zl t ,S7/q'�`" 15 _ CENSUS TRACT <br /> Owner's Name S T� Phone <br /> 4 <br /> Address I' ? 1 s T city TGG/rTlfy <br /> Contractor's Name <br /> L' License # 71 L G 2 Phone W2-5-"7 <br /> NEW WELL DEEPEN RECONDITION RECONDITION /_� DESTRUCTION / 7 <br /> TYPE OF WORK (Check) : <br /> PUMP INSTALLATION I / PUMP REPAIR / / PUMP REPLACEMENT I^T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ . PIT-.PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPE FICATI S . <br /> Industrial Cable Tool Dia, of "Well-Excavation " <br /> Domestic/private Drilled Dia. of WelV Casing <br /> r Domestic/public Driven Gauge of Casing /La <br /> Irrigation Gravel Pack Depth of .Grout Seale <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H <br /> _ s <br /> PUMP REPLACEMENT: / / State Work Done Yu <br /> PUMP REPAIR: / / . State Work Done <br /> .PESTRUCTION _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 <br /> and the StateLof California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> will'?furnish the San Joaquin Local Health District a <br /> after completion of .my work on a new well, I <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 TITLE 67' aL _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> df <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 !^� <br />