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77c4m �6 <br /> ' SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOS. <br /> ,:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> hPPLICATION .FOR WELL GONSTRtJCTION OR PUMP PERMIT Permit No. - 22 <br /> THIS PERNIIT.EXPIRES YEAR FROM BATE ,ISSUED Date Issued <br /> (Complete In Triplicate) . <br /> Application I is her'03ay- ,made to the <br /> ��uin Local Health This application istmade infor <br /> compl.�.ancea permit tw3�thnSanu3oaqu�.n <br /> and/or install the work herein described <br /> County Ordinance .Na. :1862 and the. Rules and Regulations of the San Joaquin Local Ftealth District. <br /> JOB ADDRESS/LOCATION 't=, . <br /> h CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> City U <br /> Address' <br /> r License # Lia 7 -g ne <br /> Contractor's Name. c� <br /> TYPE OF WORK (Check)-. NEW WELL/ ! DEEPEN! 1 RECONDITIONPUMPESTRUCTION REPLACEMENT /_7 <br /> MP <br /> PUMP INSTALLATION / ! PUREPAIR / <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 SPEC 1%j <br /> ' Industrial Cable T Dia. of Well Excavation <br /> Industrial <br /> - Drilled Dia. of Well Casing <br /> DomeDomestic/public Driven Gauge of Casing <br /> ' <br /> gation IrriGravel Pack Depth of Grout Seal <br /> i Rotary Type of Grout <br /> Other- - = <br /> Other Other Information <br /> -�TbI P INSTALLATION: Contractor CE4 �+JC� � a►ce �' <br /> Type of Pump e P H.P. <br /> =-PUMP REPLACEMENT: / State Work 'Done w <br /> PUMP -° EPAIR: <br /> /� State Work Done Q <br /> Approximate Depth <br /> DF�TRUCTION OF WELL: Well Diameter. <br /> Describe Material..and Procedure <br /> agree to with all lyras and regulations of the San Joaquin Local Health District <br /> I hereby comply P Y <br /> *` and -the State of California pertaining,to or regulatinwelZ ''construction. Within FIFTEEN DAY <br /> g <br /> -.after conipletian of my work on a new well, I will furnish the San Joaquin Local Health District 6 <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> i information is true to the best of my kiior�rled be3ief. <br /> TLE s''&C41 <br /> . <br /> SIGNED <br /> E SIDE) <br /> (D W OT PLAN ON REV S <br /> FOR DEPARTMENT USE ONLY <br /> PICAS I DATE <br /> APPLIGATtON ACCEPTED -BY <br /> ADDITIONAL COMMENTS: PHASE NSPECTION <br /> PHASE II TION INSPECTION BY DATE - G <br /> INSPECTION BY A <br /> CALL- 'OR A GR€3UT°-INSPECTION TION -TO •GROUTING' --AND.,-FINAL INS1? 5/731M <br />