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s <br /> f !� SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> F. OF FIC sE 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z -133. � <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7tF <br /> t ,. (Complete In Triplicate) <br /> Application is. hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ox install the;,worlc herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No.�1862 and the :Rules�,',d Regulations of the San Joaquin Local Health Dist rict. <br /> rcrsFc ; mlX-�' I.F7-3o6��9 i <br /> �(- <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION • • +� 4 <br /> Phone �• . <br /> Owner's Name <br /> City <br /> Address _ n. <br /> Contractor's Name +V�d� s. License # 7'al.�"�Phone <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN ]�I RECONDITION_/ / DESTRUCTION IT r <br /> PUMP INSTALLATION / / PUMP REPAIR ./ / PUMP REPLACEMENT <br /> Other ;/ <br /> 3 'l- <br /> DISTAi�10E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPQOL/SEEPAGE PIT OTHERS <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private. �f� Drilled <br /> Dia. of Well Casing <br /> Domestic/public t . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of. Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type'�of Pump <br /> r S <br /> ` =?O Ali <br /> PUMP REPLACEMENT: State Work,Done <br /> . •PUMP' 'REPAIR: / / State Work Done. <br /> ,DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> m t <br /> is 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 of the`well and notify them before putting the-well in, use, The above <br /> information is true..to the best of knowled e— belief. - <br /> I ITLE <br /> SIGNED <br /> LO PLAN ON R RSE SIDE) ' <br /> + r FOR DEPARTMENT USE ONLY <br /> PHASE I DAT 7 <br /> APPLICATION ACCEPTED BY G��'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION " PHASE III/ INAL INSPECT ON <br /> INSPECTION BY . - .DATE INSPECTION BY ��DA!T�!E <br /> . CALL FOR A GROUT INSPECTION.-PRIOR TQ GkOUTINGG:AND.FINAL-INSPECTION. s/7�# :_ <br />