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n <br /> J .4y a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF--0£. OFFICE USE: 1601 E. Hazdlton-Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> F- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � /6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .Date Issued 3 <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 Ordi 19��o.-,3462 and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> SL��E s15 <br /> JOB ADDRESS/LOCATION &OU "' CENSUS TRACT <br /> Owner's Name Le' ,_.. I <br /> P ._ Phone ', .�[� <br /> �`Q <br /> Address {, - City <br /> Contractor's NameLicense # ?/,-?Phone <br /> TYPE OF WORK (Check) : NEW WELL R DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT /- <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC T&NK SEWER LINES PIT PRIVY <br /> 1/ 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 <br /> Domestic/public Driven Gauge of Casing _ _ <br /> Irrigation 40 <br /> Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ` jej. zpt• <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / J State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFGTRUCTION 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 atn�-sem Le-1- TITLE C <br /> (DRAW PLOT PLAN ON REVERSE SI)E) <br /> FOR DEP . MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCE E3 - 7-7 <br /> ADDITIONAL COQ <br /> P I)r/0,kOUT INSPECTION P I/F INSPECTTM <br /> INSPECT ON BY DATE - INSPECTION--B —Z <br /> CALL FOR A GROUT INSPECTION PR16R TO ROUTING AND FINAL INSPECTION. - <br /> E H 14265/731mrl <br />