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.. <br /> AN JOAQUIN LOCAL..HEALTH DISTRICT <br /> For-*:01 FICE USE: 1601 E. Hazelton;Ave; ,-;Stockton, Calif. <br /> Telephone: J209) 4666781 <br /> APPLICATION FOR WELL CONSTKUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> i .� (Complete ,ln Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to :canstruct <br /> and/or install,.the:work herein described. , .This application is made in compliance with San Joaquin <br /> County 0rdinsnc�vNo.:. 18b2 and .the Rules- .and Regulations.,of the San Joaquin Local Health District. <br /> JOB ADDRESSfLOCATION / 4, Y- ..Q Lt.� CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address City <br /> License #t -'hone <br /> Contractor`s Name �/ t . <br /> TYPE OF WORK (Check) : NEW WELL -/ / DEEPEN '/ / RECONDITION /�/ DESTRUCTION /_ <br /> .PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESa PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> INTENDED USE 11 TYPE OF WELL CONSTRUCTION SPECIFICATIONS �R <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 Other Information ' <br /> PUMP INSTALLATION: Contractor S . . <br /> _ - Type of 'Pump / H.P. --L� . . . <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> State Work Dane <br /> s <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,j <br /> j I hereby agree to comply with all lavas and regulations of the San Joaquin Local Health District <br /> !j 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 Grill .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 kno 1e d belief. <br /> SIGNED tdi�'• �Gd ITLB C. . <br /> ;i <br /> fDMP T PLAN .OJ.MVERSE SIDE) AA <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED -BY DATE v2 <br /> 11 ADDITIONAL. COMMENTS: <br /> PHASE II UT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE r <br /> __ ' <br /> - CALL FOR-A..GROUT�TNSPECTION-PRIOR-TO-GROUTING AND FINAL_.I. CT <br /> f <br /> 51 731M <br /> u ,..amu — <br />