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A , <br /> SAN 19AQUIN LOCALHEALTH DISTRICT <br /> FOP. 6-1-FI-CE USE: 1.601 E. Haz6ton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I. 7.s-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) II � <br /> Application is hereby wade 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin LocaII Peal.th District. <br /> \ .. T, <br /> JOB ADDRESS/LOCATION - �. i L b ST CENSUS TRACT jjq <br /> Owner's Name Poneyl(s <br /> . <br /> Address '. itY\ !, <br /> cs c <br /> Contractor's Name ��[ l �,) 0t1 [,4 License # :Phone <br /> IN <br /> TYPE OF WORK (Check): NEW WELL Y DEEPEN /-7 RECONDITION / / DESTRU N J? <br /> MP <br /> PUMP INSTALLATION /Y/­PUREPAIR / / PUMP REPLACEMENT /7 } <br /> Other <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK i get, '♦ SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F � <br /> _ Industrial Cable Tool Dia. of Well. Excavation $ <br /> Domestic/private Drilled Dia. of Well Casing 45,;(Ij <br /> il ?� <br /> Domestic/public Driven Gauge of Casing E I <br /> Irrigation Gravel Pack Depth of Grout Seal 'I i <br /> Other / Rotary Type of Grout o f V, [bra v4 <br /> Other Other Information i� I <br /> PUMIP INSTALLATION: Contractor I <br /> Type of Pump I� H.P. ' <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> i <br /> • le ' <br /> ,DFfiTRUCTION OF WELL: Well Diameter ApProximatDepth <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 /> informatipp is true to he est of my knowledge and belief. <br /> SIGNED <br /> TITL4><2" <br /> (DRAW PLOT PLAN ON REVERSE SIDE) I� <br /> FOR DEPARTMENT USE ONLY <br />} PHASE I DATE IO Z <br /> APPLICATION ACCEPTED .BY L r ` <br /> ADDITIONAL CO1,1M''NTS: �p <br /> PHASE II GROUT IMPECTIN PHA I I/FI iNSPECTION <br /> INSPECTION BY DATE r ? �- INSPECTION BY ,DATE <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />