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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —POT-OI.IICE USE: V 1601 E. Hazelton Ave. Stockton Calif. <br /> 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 `j,C <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 th��e// San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Al S SO / 0 ` EY S T��� <br /> Owner's Name Z A" 6/V C';,LC/N Phone q31 2 8 '3 <br /> Address / 2- r_ City <br /> Contractor's Name / License #jjj t'LQ Phone gco,7 �! <br /> TYPE OF WORK (Check): NEW WELL A7 DEEPEN _/ RECONDITION i / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TLiK D ' 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 /p `` <br /> _ 2(_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C-V <br /> Other � _ Rotary Type of Grout 68E% <br /> Other Other Information . <br /> Q <br /> PUMP INSTALLATION: Contractor ?;K- 2 7 <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / f State Work Done <br /> .DF9TRUCTION 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 ITLE <br /> (DRAW PL 014 REVERSE SID <br /> FOR DErARTMgNT USE ONLY <br /> PRASE I , <br /> APPLICATION ACCEPTED BY �� E r2 / % / � DATE <br /> ADDITIONAL COMI�,LINTS: <br /> PHASE II GROUT INSPECT" N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT TSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />