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^Q r <br /> Gam{-61 <br /> SAN JO,9QU1Njf.OGAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone':'­ Q09)(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION `OR PUMP PERMIT Permit No.�3_�336 � <br /> THIS ,PERMIVEXPIRES 1 YEAR FROM 'DATE ISSUED`J'` Date Issued <br /> {Complete 'In Triplicate) r :, <br /> Application-is.hereby ,made AoIthe'San Joaquin 166al Health District for a permit ,t`o construct <br /> and/or install the work herein described. This 'applicatioh is made 'in- compliance' with Sari'Joaquii <br /> ' County Ordinance'No.". 1862`iiid the Roles and Regula ions of the San'Aoaquin Local Health District. <br /> JOB ADDRESS/LOCA ION CENSUS TRACT <br /> � s —.fit _ '++ •}^i'•.. yr _ .3 -n ,.. r.. i f— .. <br /> Owner's 7Name ' '7' •rc;?2 x 4. , Phone ' <br /> k , <br /> Address' k - <br /> IContractor's NameHUI ��� y' (-,L-t U License #_2 z7!f/Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /-T DESTRUCTION; /_7 <br /> PUMP INSTALLATION / / . REPAIR / / PUMP REPLACEMENT /-7 ' <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK (SEWER,LINES�_ PIT. PRIVY <br /> SEWAGE DISP IELD-----Z— GESSPOOL/-SEEPAGE "PIT -y-' OTHER <br /> 7. <br /> INTENDED USE 'TYPE OF ELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Do stir/public Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other - Other Information - <br /> E PUMP INSTALLATION: Contractor .� <br /> Type of Pump------ _ -. �l` '.< H.P. <br /> PUMP REPLACEMENT: / / State Work�Done <br /> PUMP `REPAiR:'c` "® / / State Work Done <br /> ,DESTRUCTION 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 /> land the State -of California pertaining toJor regulating well construction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the4well and notify them before putting the well in use. The above <br /> information isYrrue to the best my knowledge and belief. <br /> SIGNED /A4-�'l ,; TITLE t��Z <br /> LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> L PHASE I ' <br /> ADDITIONAL COMMENTS: iJ _�� <br /> APPLICATION ACCEPTED BY DATE O ._ <br /> PHASE II GROUT-INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY DATE , /7- <br /> CALL FOR .A•G.ROUT...INSPECTION..PRIOR_TO GROUTING AND FINAL INSPECTION. <br /> k E H 1426 <br />