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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT .'01FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- Zd <br /> THIS. PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby ndde 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 /> 5-0 <br /> JOB ADDRESS/LOCATION U?-�� CENSUSTRACT <br /> Owner's Name c� Al �.p D 4-f- c-A _` Phone <br /> Address 3.. G � A G City <br /> Contractor's Name A16 7/& [k 5'Lc. J .2,L License #a5-olp 3 Phone}!1 -43 <br /> TYPE OF WORK (Check) : ,NEW WELL / / DEEPEN /_7 RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION J(/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> tther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> AWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS QV <br /> Industrial ' Cable Tool Dia. of Well Excavation �ll <br /> Domestic/private Drilled _ Dia.: of Well Casing N <br /> Domestic/public Driven 'Gauge of Casing ' / 2,- <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Other i _�(� Rotary Type of Grout <br /> i� Other Other Information ' r, <br /> - tontractor <br /> PUMP INSTALLATION: <br /> Type of- Pump r = .r H.P. - <br /> ,y+ - <br /> PUMP REPLACEMENT: .f / Statei Work Done <br /> P <br /> PUMP 'tEPAIR: �/ / Stated Work Hone <br /> .V 5 <br /> .DR-,TRUCTION OF WELL: Well Diameter--� Approximate Depth <br /> - ,$escribe Material and Procedure <br /> T 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.Pork 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 toithe best of my knowledge and belief. <br /> SIGNED '� TITLE <br /> •PL LAN ON REVERSE SIDE) <br />` �II <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> I DATE / - C�- <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II-_G.ROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY , N� DATE INSPECTION BY `tt DATE151 <br /> 'S-1'1�✓S� <br /> CAT:L-F'OR-A-GROUT-INSPECTION-PRIOR TO GROUTING AND FINAL INSPE ION.r r <br /> E H 1426 5/731M ,' <br />