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• <br /> Co � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFF E USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. IS-IS 5 P <br /> THIS PERMIT EXPIRES 1 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �Oo , <br /> JOB ADDRESS/LOCATION CS40L nck- ( ye pg Y CENSUS TRACT ! tS- Z3 -01f <br /> Owner's NameL�rm p o Gt Y C� Phone // <br /> Address �40 C-!//C� 14- CCC LtrRt �� City ' 54 427 <br /> Contractor's Name �/ a4.,- -0 License # C93, W Phone 4', -IN 7 4 <br /> TYPE OF WORK (Check): NEW WELL/% DEEPENRECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUP1P REPAIR _13?/ PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> AC Industrial: Cable Tool """ Diaof Well Excavation !' <br /> Domestic/private . . Drilled. Dia. of Well Casing C <br /> 'Domestic/public Driven Gauge of Casing <br /> Irrigafion Gravel Pack 'Depth of Grout Seal <br /> Other - '. .Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Ar wl <br /> T9Pe of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Done it <br /> PUMP 'tEPAIR:. ��o <br /> State Work Done pm � /,{Q�S�' �.kJ. 12:2I4e ^1ii <br /> .DFsTRUCTION 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 before. putting the well in use. The above . <br /> information is true-..to .the best. of. my know-ledge and belief. <br /> SIGNED .. TITLEd� r <br /> RA PLAN ON ' VERSE SIDE f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE . . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY .DATE _. . INSPECTION BY - DATE <br /> CALL-FORA•GROUT-I"NSPECTION•-PRIOR-TO GROUTING.AND.-FINAL INSPECTION._ . _ . ., <br /> E H1426 _. 5/.731M�� <br />