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�F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 . OI ICE USf 1601 E. Hazelton Ave. , Stockton, Calif. CANNED <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7s=J,L/7Ja <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby trade 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. 1.862 and the Rules and J_teg4ilations of the San Joaquin Local. Health ]district. <br /> JOB ADDRESS/LOCATION J CENSUS TRACT f <br /> Owner's Name <br /> F Phone ��,� <br /> city <br /> Address r <br /> 7tj <br /> / License' Chanel ra <br /> Contractor's Name �� ` <br /> TYPE OF WORK (Check) : 'NEW WELL I I DEEPEN / / RECONDITION / f DESTRUCTION f-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT IT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (, <br /> Industrial Cable Tool Dia. of Well Excavation (U <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ -- <br /> Other Other Information <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP UPAIR: / / State. Work Do <br /> DESTRUCTION OF WELL: Well Diameter TAp=mate 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 ,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 the best of my knowledge and belief. <br /> SIGNED 71c TITLE <br /> (DRAW PLOT FLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE NSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION." '� <br /> 7 u 1h9A - 5/731M 731M <br />