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_ SAN JOAQUIN LOCAL HEALTH DISTRICT 15IOC. OF,ICE USE: ✓ 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 121 <br /> THIS PERMIT EXPIRES l 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 Joaqui <br /> County Ordinance No. 1.862 and the. Rules and Regulations of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION <br /> Z/01 CENSUS TRACT <br /> Owner's Name� CYli4/.�' _T 1----> <br /> Address � � .e /.5_ - -' City <br /> Contractors Name .G. r License ��� Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION I / DESTRUCTION t7 6\ ; <br /> PUIQ INSTALLATION PLW REPAIR / I PUMP REPLACEMENT /� <br /> ff <br /> Other / / i <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 Tool. 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: ` / / 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 Drell. 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 RE the well and notify them before putting the well in use. The above <br /> information the be of my knowledge and belief. <br /> SIGNED TITLE [�•Q� <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL =MNTS: <br /> PRASE II GROUT INSPECTION PHAaE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B AAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />