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SAN JOAQUIN LOCAL HEALTH DISTRICT .k <br /> 70r.-671,EICE USE. 1.601 E. Hazelton Ave. , Stockton, Calif. ¢: <br /> Telephone: (209) 466-6781 t <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 7S- 96U) t. <br /> THIS PERMIT EXPIRES l 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r f t, <br /> JOB ADDRESS/LOCATION <br /> 25-3 oI CENSUS TRACT <br /> Owner's Name ,`C x Phone . � ' <br /> Address city <br /> Contractor's Name License Phone <br /> - _- %000, - - - <br /> TYPE OF WORK (Check) : NEW WELL/�EEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT I�T <br /> Other / f <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 able Tool Dia. of Well Excavation ,iz G.1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ted' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Az-yt- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br />'T PUMP-'tEPAIR: <br /> ,DFCTRUCTION 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 .�. s'11.sys.��-i'� -- — <br /> J- .� <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I - , j <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE I . IFI INSPECTIllr/�z INSPECTION BY DATE -7- .�—'INSPECTION BY f' DATE <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL,INSPECTION. <br /> 5/731M <br /> 4 E H 1426 � <br />