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S <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF. OF ICE USE: " 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> 441t .19APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Via!- <br /> VIAXW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �J/- <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.wori 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 �ffl-�r/ .. _ CENSUS TRACT , <br /> Owner's Name Phone <br /> Address /� / City ' <br /> 3 <br /> Contractor's Name /tom( License Phone <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN /_7 RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PLW REPAIR / I PUMP REPLACEMENT /7 <br /> 'Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAINK 14�4 SEWER LINES s PIT PRIVY ,�p �' <br /> EWAGE DISPOSAL FIELD,�DA& CESSPOOL/SEEPAGE PIT jMV OTHER <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFi ATIONS <br /> Industrial1 Cable Tool Dia. of Well Excavation. <br /> Domestic/private�� �rilled Dia. of Well Casing., <br /> � __ omestic/public Driven Gauge of -Casing <br /> Irrigation V-Gravel Pack Depth of Grout Si = f r <br /> Other /t Rotary Type of Grout <br />► ib Other Other Information <br /> PUMP INSTALLATION: ,. Contractor �� <br /> Type of Pump <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: <br /> / / -State Work Dane <br /> ,DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comp,y 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 mjwork on a new well, I.will furnish 'the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o the well and notify them before putting the well in use. The abo <br /> information is true tol�lthe best-of my knowledge and belief. <br /> I � <br /> SIGNED , � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �= 7 <br />� APPLICATION ACCEPTED Bl' f DATE 1- 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS GROUT INSPECTION PHASE III/FINAL INSPECTIjDN <br /> INSPECTION BY ih DATE5= - 7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSP ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ,, E H 1426 ,. 'il. X. 5/731M <br />