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SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> Fo r.:0 ,EICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone: (209),1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7��4/.4_1 <br /> 7,y- 0a.P P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED Date Issued -�5 <br /> (Complete In Triplicate) <br /> Application is -here by made to the San Joaquin .Lucal 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:. CENSUS TRACT ' <br /> ` ?( 0 <br /> Owners Name �i1 O <br /> Phone?o ? <br /> Address ZIF fre),, r .5 �. City Ac" <br /> Contractor's Name 1V0 0 I '#1 r. License Phone <br /> J <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ ;/ RECONDITIONI / DESTRUCTION 17 <br /> PUMP INSTALLATION % PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other ./_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS � <br /> Industrial `Cable Taal Dia. of Well Excavation <br /> Domestic/private. Drilled Dia. of Well Casing - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack' Depth-of' Grout Seal <br /> Other Rotary ;Type of Grout ' <br /> Other Other Information <br /> { <br /> PUMP INSTALLATION: Contractor * - <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP PAIR: / JState Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameter _—� Approximate Depth <br /> Describe Material and Proceduret, <br /> I hereby agree to comply with all laws and regulations 'of the San Joaquin Local Health Distric <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 D S REPORT of the well and­notifj them before putting the well in use. The above <br /> informat'on. i txa the best of my knowledge and belief. <br /> P_a&;� <br /> SIGNED TITLE <br /> (DRAW PLOT FLAN ON REVERSE SIDE} <br /> S FOR DEPARTMENT USE ONLY <br /> PHASE I �"{ <br /> APPLICATION, ACCEPTER BY -�• "�'� Yi" / DATE j 3 I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �a INSPECTION BY DATE �. , <br /> CALL FOR-A-GROUT .INSPECTION PRIOR TO GROUTING AND_FINAL INSPECTION. <br /> I -,. S/717[m <br />