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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0F.,OFF CE USE: 1.601. E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 riz <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) I <br /> Application is hereby rude 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 d <br /> County Ordinance: No. 1862 and the Rules and Regulations of the San Joaquin Local. health District. <br /> JOB ADDRESS/LOCATION �� m� e / ��°� S o 40�I ENSUS TRACT <br /> er <br /> Owner's Name 4,4rC-r-OP Phone <br /> Addressf a 0 City <br /> 3 <br /> Contractor's Name ; Licensed7y�"Ighone �, � <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/_/ RECONDITION / I DESTRUCTION /-7 <br /> PUMP INSTALLATION / ./ PUMP REPAIR /,/ PUMP REPLACEMENT <br /> Other /'/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED <br /> TYPE ``OCableWELL . <br /> Toole Dia. of We11CONSTRUCTION <br /> ExcavatioSPECIFICATIONS <br /> 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 ',e Type of Grout <br /> - Other Other Information <br /> PUMP INSTALLATION: Contractor = - <br /> - Type of Pump .r x H.P. l �✓ <br /> PUMP REPLACEMENT: /x/ State Work Done'. <br /> . ,��' -Lfvs( ,* � <br /> PUMP 'ZEPAIR. / / State Work Done <br /> ,DFgTRUCTION 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 efore putting the well in use. The above <br /> information is true to the best of myb <br /> . knowledge -- � . lief <br /> ..SIGNED , <br /> (( L_� ` TLE /fad <br /> (D t OT -PLA ON RE SE SIDE) <br /> FOR TMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED .B .J 7-. DATE / 6AZ3/23S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA40 JTINAL <br /> INSPECTIO <br /> INSPECTION BY DATE INSPECTIONBY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I I0 <br /> E H 1426 5/731M <br />