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F � R <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f'0r.:'0FF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.! - 17 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _-� J3 <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;a1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION yC ` 4242 MeM CENSUS TRACT , <br /> Owner's Name . Zf/L Phone <br /> Address o D� � �, City <br /> Contractor's Name LicensedPhone ' YG <br /> { <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN '/—/ RECONDITION I I DESTRUCTION 1-7 <br /> PUMP INSTALLATION f PLW REPAIR /k/ PUMP REPLACEMENT /7 <br /> Other., / <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private- Drilled Dia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary. Type of Grout <br /> } Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - t ate, a H.P. . <br /> PUMP REPLACEMENT: 1 � } <br /> / J State Work Dane <br /> PUMP `tEPAiR: tate Work Done f 4,j, <br /> ,DFRTRUCTION 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 thein before putting the well in use. The above <br /> information is true to the best of my owledge a elief. <br /> SIGNED �) P/ <br /> // T _ <br /> ' 14 ITLE <br /> (DON R RSE SIDE) <br /> • OR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED .BY � DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL-FOR.A;GROUT INSPECTION-PRIOR-TO-GROUTING.-AND-FINAL INSPECTION. ^ <br /> E H 142b 1�17 q,, <br />