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4 .F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R OFFICE USE: 601 E. Hazelton Ave . , Stockton, Calif. " ` <br /> E \ Telephone: (209) 466•-6781 <br /> ` <br /> F PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 23 -7 <br /> �:. (Complete In Triplicate) <br /> r-�lication is hereby made 'to. the San Joaquin Local Health District for a permit to construct <br /> I '/or install the work herein described. This application is made in compliance with San Joaquin <br /> inty Ordinance No. 1862—ai-rd the Rules and Regulations of the San Joaquin Local Health District.! <br /> D <br /> ADRESS/LOCATION S� .0 ,/v CENSUS TRACT <br /> a I¢ I� <br /> ier'.is NameZ4 S EL A X Phone y.4s-461 . <br /> ,5 C jgAo R <br /> rens City <br /> tractor's Name 7--,� S_r� � –5 / License # Phone S ,.Z2V ] . <br /> ?E OF WORK (Check) : NEW WELL / / DEEPEN / f RECONDITION /7 DESTRUCTION /- <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> r!TANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> iIINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> — jlndustrial Cable Tool Dia. of Well Excavation ..fi <br /> T�jDomestic/private Drilled Dia. of Well Casing <br /> :IDomestic/public Driven Gauge of Casing . <br /> lIrrigation Gravel Pack Depth of Grout Seal <br /> I10ther Rotary Type of Grout ' <br /> Other Other .Information <br /> .2 INSTALLATION: Contractor a <br /> Type of Pump H.P. . <br /> I9 <br /> REPLACEMENT: / / State Work Done <br /> REPAIR: /t f' State Work Done 4 <br /> lb <br /> t>-xRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,_',reby agree to comply with all laws and regulations of the San Joaquin Local Health District f <br /> E the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r"ir �6mp'letion of my work on a new well, I will furnish the San Joaquin Local Health District a ' <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> :ormati6n is true to the best of my knowledge and belief. <br /> QED TITLE <br /> �I (DRAW PLOT LAN ON REVERSE SID <br /> FOR iPARTNENT USE ONLY s <br /> iE �'I <br /> KATION ACCEPTED BYE, �h`� � DATE <br /> )ITIONAL COMMENTS: i <br /> r <br /> PHASE Il GROUT_INSPECTI.ON PHASE III/FINAL INSPECTION <br /> ?ECTION BY DATE INSPECTION BY. DATE <br /> k <br /> CAI;I, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> s' H 1426 4172 1M <br /> � Ilio <br />