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r SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> For. O1FILE USE:- ]601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�_7 <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 /> JOB ADDRESS/LOCATION /�� z CENSUS TRACT - <br /> Owner's Name PeAWL <br /> Phone <br /> Address r 1.�d A4 y��J'�__ � City <br />,Contractor's Name -g - -' -' "License fid_ Phone <br /> we <br /> TYPE OF WORK (Check) : NEW WELL /7701," DEEPENS/T/ .> RECONDITION_/ / DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <br /> — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 99 , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial !-' Cable Tool Dia. of Well Excavation 1� <br /> Y Domestic/private Drilled Dia. of Well. Casing Q <br /> Domestic/public Driven Gauge of Casing 71;L- <br /> Irrigation <br /> 2Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout Ce�l7 <br /> Other Other Information �} <br /> PUMP INSTALLATION: Contractor v <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '2EPAIR: /_/ State Work Done <br /> .DFcZTRUCTION 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 , TITLE <br /> t (DRAW PLOT PIAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I /FI INSPECT N <br /> INSPECTION BY DATE s / INSPECTION BYDATE �' �• <br /> CALL FOR A GROUT I► CTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> H a2� =` _ .5�/73 <br /> 1r�T=C <br />