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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I OF. 01 ILL�USi : 1601 E. Hazelton Ave. , Stockton', Calif. <br /> Telephone: (209) 466 -6781 A <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l_- 3 81 <br /> 1` <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED DateIssved <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 HA lth District.- <br /> y CENSUS TRACT " <br /> JOB ADDRESS/LOCATION ___23 3 <S <br /> Owr►er s Name <br /> Phone <br /> City <br /> Address _ A 11/1 yE_ - Y <br /> contractors <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /—/ _kW REPAIR I / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 3SEWER 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 <br /> k � Domestic/private - Drilled Dia. of Well Casing <br /> c Driven Gauge of Casing I� <br /> Irrigation Gravel Pack Depth of Grout Seal 11 <br />� • t er Rotary Type of Grout �M <br /> Other Other Information -SgALLQ �� fill LCA R� <br /> PUMP INSTALLATION: <br /> F - <br /> -- ContractorH.P. <br /> Pump I- <br /> ;% <br /> iU?,1P <br /> REPLACEMENT: / / State Work Done <br /> -------------- <br /> _77 PUMP `ZEPAIR: / / State Work Done <br /> ,DFcT.RUCTION OF WELL: Well Diameter Approximate Depth <br /> -- Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Heialth District .` <br /> and the State of California pertaining to or regulating well 'construction. WithinhFIFTEEN DAYS� <br /> after completion of my work on a new well, Iwill furnish the San Joaquin Local Health District a <br /> 14ELL DRILLERS PORT of .the well and notify them before putting the well in use. The ab ve <br /> informatio s rue to b 02o� '"y <br /> knowl dge and belief. <br /> � - ITL ) <br /> iCNED - <br /> S -- ,. <br /> j (DR LOT PLAN ON REVERSE SIDE) I� <br /> F9A DgNT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPlrvn $Y DATE <br /> ' ADDITIONAL CO`SMEN 1M <br /> I� f <br /> P �I GR INSPECTIO P I INAL INSPECTION <br /> INSPECTIO Y DATE INSI'ECTi BY DAT E - �� <br /> w CALL FOR A GROUT INSPECTION 1�RIOR TO GROUSING AND FINAL INSPECTION <br /> 5/731rs <br /> -- <br />