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r <br /> _ `` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,QUI Or FICE USI:: 601 E. Hazelton Ave. , Stockton, Calif. <br /> 0 , Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �~ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6L. 3 Jel <br /> (Complete In Triplicate) <br /> Application is hereby r,„3de to the San Joaquin Local Health District for a permit to constil.i� t <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 a Regulationt of th an Joaquin Local. lie;i t:h District. <br /> JOB ADDRESS/LOCATION l ' [` L? ear, CENSUS TRACT <br /> Owner's Name r, Phone-�,, IKY, _ <br /> '-1 c <br /> Address > City <br /> Contractor's Name _ / ' /�! L�_ License 4f Phone ?”' �jt <br /> TYPE OF 14ORK (Check) : NEW WELL DEEPEN`/ / RECONDITION / / DESTRUCTION /-7 <br /> PUIP INSTALLATION /?'PUMP REPAIR /i/ PUMP REPLACEMENT / 7 <br /> Other I I Q' <br /> DISTANCE TO NEAREST: S I TiC ' i% iK SEWER.LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T"PE OF WELL CONSTRUCTION SPECIFIC AT ONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout r <br /> Other Other Information <br /> PU:T INSTALLATION: Contractor _ ZZ <br /> n << <br /> Type of Pump H.P. __ <br /> PUS.' REPLACEME—NT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DF�TRUCTION 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 /> t,'r:LL DRILLERS ORT of the well and notify them before putting the well in use. The above <br /> information i tr to b st of my knowledge and belief. <br /> zISIGNED TITLE <br /> _ V (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r' A <br /> APPLICATION ACCsPTED BY y f�%� `'��.G'� DATE <br /> ADDITIONAL CO%ZrMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY �� DATE j�V :,Z.l- 7 INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIG : TO GROUTING AND FINAL INSPECTION. co <br /> E H 1426 5/731M `� <br />