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_ I/ SAN JOA4 UIN LOCAL HEALTH DISTRICT <br /> i'OF.-UTIICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� IJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-8 7 <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 � CENSUS TRACT <br /> Owner's Name �/t.Tr�fa - Phone �� <br /> Address City <br /> r <br /> Contractor's name Alc�.,� , LicensejOyyPhorie�� � <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -J-7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TAINK 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 <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 /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP UPAIR: / / State Work Done f <br /> DFgTRUCTION OF WELL: Well. Diameter /! Approximate Depth 76 <br /> � <br /> Describe Material and Procedure <br /> f <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 />` WELL DRILLERS REPORT th well and notify them before putting the well, in use. The above <br />` informat' r to th. s my knwledge and belief. <br /> SIGNED TITLL\- -- �� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PRASE I ROUT INSPECTION V P1iASZ' III/FINAL INS02CTION <br /> INSPECTION BY DATE INSPECTION BY DATE cT7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />