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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7Ti� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made 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 /> JOB ADDRESS/LOCATION -- CENSUS TRACT <br /> Owner's Na PhoneJ/. -7 <br /> Address ,�G� f� �� jfl�. 3 ,� F � Citys_/ .0 <br /> Contractor's Name _,� ��.[. ,L' ,- I, �)i License # jL`,(3�-3 Phone t l 2, �. <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN /_/ RECONDITION / -' <br /> _/ DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /A-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '7e'l CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA7Z ONS a••• <br /> Industrial Cable Tool Dia, of Well Excavation / ` O <br /> t� 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 ;E�1&/N <br /> Other Other Information <br /> • <br /> PUMP INSTALLATION: Contractor ,,/_Z .�„ <br /> Type of Pump _ � � - '� _ 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED _ :i��_.� r i A_ = �,r /1. , . , Oji ��_ TITLE 7 n <br /> {DRAW PLOT PLAX ON REVERSE SIDE t <br /> FOR DEPARTMENT USE ONLY � <br /> PHASE I <br /> APPLICATION ACCEPTED BY t' �? DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. OA <br /> E H 1426 7172 1M <br />