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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No'. &__J_r ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _�2a c� <br /> ii (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit toyconstruct <br /> and/or install the work- herein described. , This application is made in compliance with San Joaquin <br /> k County Ordinance No. 1862andthe Rules and Regulations of the San Joaquin Local Hedlth District, <br /> .j-qB ADDRESS/LOCATION CEN5bS TRACT <br /> ersName Phone <br /> s y City <br /> ontracr�or'a-Name BzJ�r a ry Licensed Phone- <br /> ' x ' <br /> u - .� <br /> TYPE OF WORKi Check) .NEW WELL ./ / DEEPEN •/ / RECONDITION r7_1 DESTRUCTION ../ " ,' i, <br /> : ':rr PUMP INSTALLATION f / PVMP REPAIR ' PT3MP REPLACEt+4E�IT J' „ <br /> ,Other ./% �? <br /> DISTANCE`x04NEAREST: SEPTIC TANK s =.§EWER LINES PIT PRIVY � <br /> CESSPOOL/SEEPAGE PIT OTHER� SEWAGE DISPOSAL FIELD CESSPOO ��=,,fir�"5• - <br /> INTENDED USE TYPE OF WELL', CONSTRUCTION SPECIFICATIONS <br /> .Indus.trial T Cable Tool. Dia. of Well Excavation a <br /> Domestic/private.i Dlle � , d Dia. of Well Casing <br /> Domestic/public Driven, Gauge of Casing <br /> Irrigation Gravel Fa-Ek Depth of Grout Seal <br /> Others Rotary' ,f�T'ype- of Grout <br /> - Other Other Information ' <br /> A <br /> PUMA? INSTALLATION:� :Contractor <br /> 4'Type of Pump . . <br /> PUMP REPLACEMENT. / / State Work Done <br /> :PUMP " _ ` 'Done 6)r <br /> 'WAIR: -� _ �� State Work Doe <br /> Dfi. Approximate Depth <br /> of .E ,`PRUCTION OF WELL:. Well Diameter = ` °^ <br /> Describe Material and Procedure <br /> 4�X 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 i true the best of my knowledge- �'belief,. <br /> SIGNED " TITLE <br /> rf (DRAW PLOT PLAN ON REVERSE SIDE) <br />'s FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT_,.:5 I. PAV I / NAL INSPECTIV <br /> INSPECTION BY <br /> '','tik i ';" INSPECTI DATE f <br /> _ . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> •N. 14 1 A,)r_ ri/711 M <br />