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SAN JOAQU.IN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> s APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .Ss6l� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION rJ F� CENSUS TRACT <br /> Owner's Name ©© Phone <br /> Address 7 � �"dl/ A& /1 fe -w -- City49n&2-'-P <br /> Contractor's Name d�i��-�� License # Phone <br /> 1 <br /> TYPE OF WORK (Check) : "NEW WELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLAT / J PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> ' <br /> Other lr` - <br /> DISTANCE TO NEAREST: SEPTIC T/UiK SEWER LINES PIT PRIVY <br /> "-`SEWAGE DISPOSAL FIELD &nn/,f®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 1' Gravel: Pack' Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information i <br /> i <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: / State Work Done ` <br /> PUMP TtEPAIR: / f State Work Done <br /> i I <br /> y , <br /> DFIzTRUCTION OF WELL: - Approximate Depth <br /> h <br /> re Cr&g teia and Procedure <br /> I hereby aW`d -0�nR, Yf rxth,all Mavis and regulx,s of the San Joaquin Local Health District <br /> E and the St y `61: <br /> aX��o k,aopja0taining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after campetio�ar;,a£,rmy;,work on a new well, I will furnish the San Joaquin Local Health District a <br /> a WELL DRILLED R—E"FORT of putting the well in use. The above <br /> ;i.nformatiorrit'fr'ue to the'best of my knowledge and belief. <br /> ✓Z%C - ti r TITLE <br /> wi SIGNED <br /> a (DRAW P e" LAN ON REVERSE SIDE) <br /> y S-QC KTOi 1, VOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED .BY f ,,,,, DATE <br /> ADDITIONAL -NTS; <br /> PHASE II EROUVINSPECTION PHASE III/FINAL INSPECZJ,ON <br /> INSPECTION BY DATE INSPECTION BY /—/ �� -.T/ DATE <br /> t <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> -- ._� ef.72zv <br />