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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'0 -"0USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued 6-2-2 <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 spade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �s <br /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name Phone Y3S " =5^7 <br /> 1 . <br /> Address < City <br /> Contractor's Name it <br /> License IU442,�-)I-phone f1ff =.2r <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/ / PUMP REPLACEMENTf :7 <br /> Other ./k-7 /.��• (,�J�y -- / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 14 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INT_. BED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "k4 <br /> Indid ial Cable Tool Dia. of Well Excavation („ <br /> 'Dosnestic./private Drilled Dia. of Well. Casing <br /> . osnes ip/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 41, Other Rotary Type of Grout <br /> Other Other -Information <br /> PUIV INSTALLATION: '.Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 40' f�/ State Work Bone } <br /> PUMP UPAIR: State Work Dome <br /> 'f I3F- TRUCTION OF WELL: Well Diameter _ - Approximate- Depth <br /> Describe Material and Procedure <br /> I herebyagree to comply with all lawsandregulations of, the San Joaquin Local Health District <br /> and the State of California pertaining to or ,regulating viell ''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"thd wel:1 'andncitif`them, before putting the well in use. T'he dUd e <br /> information is true to,,.the,,best_of my knowledge and-belief. <br /> r� C <br /> i SIGNED Ile TITLE <br /> fff4ZZ(D:R�AW�..PLOT PLAN ON REVERSE SIDE) <br /> FOR--DEPARTMENT USE ONLY <br /> PHASE I �* 10- <br /> DATE <br /> APPLICATION ACCEPTED BY C. f� a �a <br /> ' ADDITIONAL COMMENTS: -0 <br /> PHASE II G UT IN 'TION P II / INSPECTIO <br /> ' INSPECTION' BY DATE INSPECTION BY DATE •--!� _-- - <br /> CALL FOR A GROUT NSPECTION PRIOR- TO GROUTING AND FINAL INSPECTION. <br /> 5 ZM . <br />