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Z SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � Or. 0I'FTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> --- Telephone: (209) 466-6781 <br /> �~ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?,/-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5--24- 7e/,, <br /> (Complete In Triplicate) <br /> Applieatiq 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 /> t <br /> JOB ADDRESS/LOCATION 7 CENSUS TRACT <br /> Owner's Name -J-T" Phone <br /> i <br /> Address Z77 3 7 s / �Q_=� ! City <br /> Contractor's Name C.6111L License #/,j_tZ37 Phone Z- /.3 <br /> TYPE OF WORK (Check): NEW WELL /.L, DEEPEN /_7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAiVK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> v <br /> Industrial Cable Tool Dia. of Well Excavation l�( <br /> _ Domestic/private �IX Drilled Dia. of Well Casing NJ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ,jam 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 UPAIR: / / 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 and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �,�11�� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P11ASE I <br /> APPLICATION ACCEPTED BY � .-�_ DATE <br /> ADDITIONAL COM11ENTS: <br /> PHASE II GROUT INSPECTION PHASE I I ;NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />