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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7z__ <br /> t , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Pales an :e*gu �ti:o/n of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION'• 77S%��, JF�/�zG [y,5/�,vzc�e CENSUS TRACT <br /> Owner's Name, 2- :?12 L Phone �rS <br /> Address -- -G&% ? KV4/4 /_�o City C' <br /> Contractor's Name5 ���,t , %l / � License # 11,7A5/ Phone 36e9_-&4-- <br /> TYPE <br /> 6e'_-&4-TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /-7-;DESTRUCTION /_7 <br /> PUMP INSTALLATION /%PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- --- ----CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial; L_—Cable Tool „ Dia.> of Well Excavation S''. <br /> Domestic/private Drilled Dia, ofiWell Casing <br /> Domestic/public *r 'r. 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 <br /> Type of Pump H.P. <br /> . PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> �-DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ti 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 /> informatio3n/ is true to the best of my knowledge and belief. <br /> SIGNED ��/ wfT - TITLE <br /> REVERSE'-SIDE) <br /> (DRAW PLOT PLAN ON _ <br /> SE'-SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY (,�,yl - DATE T AS <br /> ADDITIONAL COMMENTS: 10 <br /> PRASE I ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY & <br /> DATE INSPECTION BY DATEra3 <br /> �4-- -- <br /> CALL FOR A.GROUT INSPECTION _PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7172 IM <br />