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Sk ,TOAQUIN LOCAL HEALTH DISTRICT <br /> f FOR OFFICE USE: 1601 -. . Hazelton Ave. , Stockton, Cali: <br /> Telephone: (209) 466-6781 O LJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI Permit No. <br /> ;J_�/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date`"Issuedl0 7`3 <br /> (Complete In Triplicate) A <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 Joaquii <br /> County Ordinance No.. 1862. and the Rules and Regulations of the San Joaquin Local';Health District. <br /> JOB C�LOCAT <br /> ADDRESS/ YON .�� / ` - i �' II. <br /> � �" �„�=z_.y (;� "z/ ��.- CENSUS TRACT Stl <br /> Owner's Name r �� ,r.� .� �~�'�I, Phone <br />� Address � � 1J`� G. I� �--� �` � <br />� - City . <br /> I Contractor's Name °. License ir6 ' Phone/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT—:./-7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES PIT PRIVY <br /> 3 r - 0 SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHN KI <br /> ER G, <br /> yak' 4 <br /> INTENDED USE TYPE OF WEL CONSTRUCTION SPECIFICAT ON <br /> Industrial Cable Tool Dia. of Well Excavation li <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 a. H'.P. <br /> PUMP REPLACEMENT: � <br /> /� State Work Done <br /> s h <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 knowledge and belief. I <br /> SIGNED I <br /> TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ..�/'•.7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. y m <br /> E H 1426 ' <br /> 7/72 1M <br />