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SAN JOAQUIN LOCAL I?.EALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton' Ave. , 'Stockton, Calif. <br /> ' Telephone:. (209) 466 .6781 <br /> 92 <br /> 06 #41 W 77- <br /> AP :LICATION_FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?u� <br /> . .THIS PERMIT 'EXPIRES 1 YEAR�i'FROM DATE ISSUED'. Date Issued <br /> (Complete In'"Triplieate) r <br /> Applicati,on'is hereby.;made .to the :San Joaquin�Local Health District form permiti -to construct <br /> and/or install the work herein described. This_'apvlication is made .in compliance -with-San Joaquin <br /> County Ordinance No.. ,1862 ,-and the Rul,es'axed=Regulations of the San Joaquin -Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's .Name Q f� d PhoneA CpJ J <br /> Address /Y• ft �� �i City J / ��K,TOAJ. <br /> Contractor's Name WOU ']"'e k. Alila. C //C; License #,e0©7/ hone .4?�19- F8/7 <br /> TYPE OF WORK (Check) : NEW WELL .& DEEPEN / / RECONDITION /_/ DESTRUCTIONS <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEME <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /j2ga 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />.DESTRUCTION OF WELL: Well Diameter A proximate Depth <br /> — ? <br /> /� <br /> Describe Material and Procedure ,/ G <br /> 0 <br /> I hereby agree to comply ith 1Iff laxig and regulations of the San JoaquinAocal HeAlth Di tr t <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 tr a to the best of my 'knowledge a d belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLO V LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />'APPLICATION ACCEPTED BY ' D <br /> ADDITIONAL COMMENTS: <br /> PID T INSPECTION P SPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL FORT NCTIQN PRIG 'TO . ROUTING AND FINAL INS N. <br /> E. H. 1426 ' / <br /> 4 72 IM ce <br />