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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PFICE. USE. 1.601 E. Hazelton Ave. , Stockton, Calif,. <br /> Telephone-: (209) 466-•-6781 <br /> APPLICATION FOR WELL>CONSTRUCTION OR PUMP PERMIT Permit No. Zz_ <br /> THIS PERMIT EXPIRES 1, 1EAR,TROM DATE ISSUED Date Issued __r <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,,: 1862 and the Rules- and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION j" CENSUS TRACT <br /> Owner's Name7157�f'lfe,—I Zzood �! -- Phone �7 <br /> Address J) City <br /> � �� e;�b?- <br /> Contractor's Na ire License I / � Phon ---° k-'-- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PU1 ' REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> XSEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q/ �j <br /> y/ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 112 Ce v- <br /> Irrigation. Gravel Pack Depth of Grout Seal ) � � <br /> Other _ Rotary Type of Grout <br /> Other Other Information _�S/ h-- �2 20 MC { <br /> PM INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - <br /> PUMP TEPAIR: / / State Work Done <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> p P <br /> '± I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ;f and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> ' after completion of my work on a new wrell, 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 gptrue to the best of myknowledge and belief. <br /> SIGNED TITLE <br /> ;p (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ON Y <br /> a PHASE I .�- <br /> APPLICATION ACCEP D . Y ADATE f(Yl <br /> ADDITIONAL COMi ' <br /> P S II T INS PEC TON <br /> P S II / AL INSPECTION <br /> INSPEC ION BY DATE 2 INSPECT' <br /> =IDAT ].t-,CALL�FOR�A,GROUT---INSPECTION-PRIOR..TO GROUTING AND FINAL .INSPECTION.H 142& <br />