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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T-R-SFT 61--, ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 173_ 7o�,ro <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/LOCATIONiq CCTr7(M (Xr CENSUS TRACT <br /> R0�"'L�` <br /> Owner's Name AIM S T44tz- Phone 3003 <br /> Address city �S C A),&'j <br /> Contractor's Name �, I/ S iky, License #.Z2o1s_ Phone ,,? <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR IF PUMP REPLACEMENT 1 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ►V. <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 ioc /_ <br /> PUMP 'ZEPAIR: / / State Work Done �E.tF o2l��? L ',La/n &.��bL�L� <br /> .DFRTRUCTION 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 thewelland notify them before putting the well in use. The above <br /> information is true to t es of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPART SE ONLY <br /> E I <br /> APPL <br /> APPLICATION ACCEPTED BY A . DATE <br /> ADDITIONAL CO'tC4ENT5: <br /> PHASE II GROUT INSPECTION P I INAL INSPECTION <br /> INSPECTION BY DATE DATE 2- <br /> �Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />