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tt <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FOE. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS <br /> 3 <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 6362 Ad An" CENSUS TRACT <br /> Owner's Name 10 P- /1-16 Phone <br /> Address 6.3 City <br /> Contractor's Name , r License # / 7;��hone 40, 74 <br /> U <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION -7 DESTRUCTION /-7 <br /> PUMP INSTALLATION Ig—PLW REPAIR /—/—PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Vu <br /> . ys 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 /> I y 4 <br /> Type of Pump ZTA H.P. S <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'Rj�: State Work Done Y t14-) <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 /> 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 knowled e a elief. <br /> SIGNED c-�7' <br /> a� ,e (,to0t)ULE <br /> (Z (DPW V,45T PrAM-ON REV EM SIDE) <br /> ---POR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Ci -r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 4ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY :�r <br /> DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 'I/P731m <br /> E H 1426 <br />