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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOF. OFFICE USE: 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 I YEAR FROM DATE ISSUED Date Issued i 310•.6 <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �f'/ � CENSUS TRACT <br /> Owner's Name _ �j�Q-t�l/k-P, f. ���GL�`r_�s2t�J Phone <br /> Address City' <br /> Contractor's -Name - �_ i�f!! License # ;�-IPhone +. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN '/ I RECONDITION / % DESTRUCTION /-7 <br /> PUMP INSTALLATION /4-j'PL'MP REPAIR / / PUMP REPLACEMENT , /7 . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA.'VK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> J <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 Cather Information ' <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> i <br /> PUMP 'REPAIR: / / State Work Done <br /> i <br /> ,DFGTRUCTION OF WELL: Well Diameter' Approximate Depth <br /> Describe Material and Procedure <br /> i <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />' V FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/ <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PWESA UjfF1INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE -� 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />