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TIC <br /> SAN JOAQUIN LOCY HEALTH DISTRICT <br /> I. OFFICE: USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71-53 A- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued H� <br /> (Complete In Triplicate) <br /> application is hereby made to the San Joaquin Local health District for a permit to construct <br /> End/or install the work herein described. - This application is Made in compliance with San Joaquin <br /> bounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION $ "7 t9 4 Q /Q S CENSUS TRACT <br /> Owner's Namel- L p Phone <br /> C� �'t7� I� �A ....._.. <br /> Address -- �L?t� _ _ City S 7&/f/- i <br /> Contractor's Namejt1S=AZ!gA / License 1�261CZ6 Phone4r,6 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '/ / RECONDITION /—/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR A PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br />-- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation q <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 <br /> Type of Pump 4r4—R H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: X State Work Done { <br /> X9TRUCTION OF WELL: Well Diameter _ .__. Approximate Depth <br /> Describe Material and Procedure � <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 4 <br /> information is true to the best of my knowledge and belief, f <br /> SIGNED TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDA/ef�< <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COWIENTS: 1 <br /> PHASE II GROUT INSPEtTIft PHAS INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATES / 7 <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING AND FINAL IN �j <br /> E H 1426 <br /> - -— r <br /> 5/731M __ <br />