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t <br /> rf SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 74/' 7-f0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - Z/0-0 <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued V <br /> (Complete In Triplicate) <br /> Applicati� is hereby made to the San Joaquin Local Health District for permit to <br /> q p 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 rFule nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION iy CENSUS TRACT <br /> r �' y <br /> Owner's Nance ell _4sc.1 /1 Z Z [1 (i Phone <br /> Address Z ' �7 yi City <br /> Contractor's Name . 4 License , ;, [ Phone ` ) <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /_/ RECONDITION /-7DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION f&=--PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK , ..SEWER LIVES ) J--PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -CESSPOOL/SEEPAGE PIT l �' OTHER - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT,;ONS <br /> Industrial Cable Tool Dia. of Well Excavation,6----Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout aeal <br /> Other ---Rotary Type of Grout ` t <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y ,- H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 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 /> infotion is true to th Wiest my knowledge and belief. <br /> SIGNED \ \ <br /> - J - TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> eFO 7ARTMENT USE ONLY <br /> APPLICATION ACCEPTED B Z. DATE 2 V <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 /72 1M <br />