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1Aa 4�aJ <br /> k ` heol est <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i For. <br /> ,OFVICE USE: 1601 E. Hazelton' Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�Z_/J6 <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Tssued 3 -�µ <br /> i I(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 acid the Rules and Regulations of the San Joaquin Local health District. <br /> f JOB ADDRESS/LOCATION 10Y �/ C ,eQ CENSUS TRACT <br /> Owner's Name Phone <br /> � 7zt <br /> Address City <br /> Contractor's Name - License # -1d2_71 one �7G 7(. <br /> r - - <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /-T RECONDITION /_/ DESTRUCTION /�. <br /> PUMP INSTALLATION IAC/ PUMP REPAIR -/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY <br /> .SEWAGE DISPOSAL FIELD v_ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ;TYPE OF WELL --------CONSTRUCTION SPECIFICATIONS <br /> Industrial, 1 Cable Tool' Dia, of Well Excavation <br /> Domestic/private. 1 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary ; Type of Grout <br /> 1 . Other Other Information <br /> PUMP INSTALLATION: Cont actor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT• _ <br /> / f State Work Done' <br /> 'PUMP "' State Work Done { <br /> ,pFgTRUCTION 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 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 bef-o putting the well in use. The above a <br /> information is true to the best of my kn edg nd h ief. <br /> SIGNED �..-� TLE - <br /> (DRAW OT PLAN ON REV SE SIDE) t <br />' R DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT =INSPECTION PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 If172zt,� <br />