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+ r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-�JJ <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 shade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S /z)oc-PJ91'r rr ,f ; CENSUS TRACT <br /> Owner's Name Phone x'23- t?,O <br /> Address L so 5, 41.A A,/ r rc A /1'U City,�1,, A <br /> Contractor's Name C/Azf-l' 1X//Fz L IL La o/.j7 C(;, License ,%"'�;0= Phone ,/ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN/_/ RECONDITION f-1 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> X Others Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 17 State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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-a notify them before putting the well in use. The above <br /> informatthe b 'c oy kree and lief. <br /> SIGNED <br /> TITLE 0 IAIAI f j(' <br /> ' DRAW P OT PLAN ON REVERSE SIDE} <br /> t <br /> R DEPARTMENT USE ONLY <br /> PRASE I ��rr <br /> APPLICATION ACCEPTED BX,_., G•� ATE <br /> ADDITIONAL COMMENTS; <br /> PHASE iTTGROUT INSPECTION PH4S4 jjj/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE b 'I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ 5/731M <br />