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1 _23 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t� c�l3 <br /> FflF."OFFICE USE: . 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to constuct <br /> Application is hereby made to theesctibeda�uThis Local <br /> istmade inrict compliance r <br /> compliance with San Joaquin <br /> and/or install, the work herein d <br /> R18G2 and the-Rules and Regulations of the San Joaquin Lnca1_ Ijeal.th District. <br /> County Ordinance No.- 47AJ., EP2-3 UG0 -07 <br /> `7 ( e`� _ �US TRACT <br /> ,TOB ADDRESS/LOCATIO V11 <br /> Phone <br /> Owner's Name <br /> y city <br /> ,Address - f7 <br /> -License i J Pt�c31C�e </ ' <br /> 'CL-nfraato-i's Name - <br /> f <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION_/_/ DESTRUCTION /� <br /> PUMP INSTALLATION / / -. PU`MP REPAIR // / PUMP REPLACEMENT /� <br /> Other <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC T&NK SEWER LINECESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> INTENDED USE TYPE OF L <br /> CONSTRUCTION SPECIFI ATIONS <br /> In trial. able Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> I omestic/private Driver: Gauge of Casing <br /> dmestic/publi.c <br /> :::jL7plorrigation Gravel. Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout ;J <br /> Other Other Information I <br /> PUMP INSTALLATION: Contractor H.P. j <br /> Type of Pump <br /> 4 <br /> State Work Done. <br /> PUMP REPLACEMENT: / / <br /> PiTMP 'tEPAIR'« / / 'State�Work Done..--=� <br /> k Approximate Depth <br /> DFQTRUCTION OF WELL: Well. Diameter <br /> Describe Material and Procedure <br /> I <br /> I hereby agree to comply with all Laws and regulations of the San ,Toaquin Local health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ill furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, I w <br /> WELL DRILLERS REPORT of the well. and notify them before putting the we 1 in use. The above <br /> information 's rue to th b st of Eny knowledge and belief. <br /> TITLE , <br /> SIGNED (DRAW LOT PLAN ON REVER5E-SID <br /> 0 DEPARTMENT USE ONLY <br /> PHASE DATE <br /> APPLI ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPEC�3ION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A`GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. pAbL 7�.1M <br />