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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: - -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7t/- ,23.5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> :lS7S r..• rOZiiuTY. �4 (Complete In Triplicate) C>d�- 070 - Of <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. 18862 and the Rules and Regulations of the San Joaquin Local Health Disgrlct. <br /> JOB ADDRESS/LOCATIO ' N1I. CENSUS TRACT <br /> Owner's Name Phone <br /> may- <br /> Address /V• /J ✓ 0' t, /I(7 City <br /> Contractor's Name ( Q� rV W,4eLicense A - Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _4�� CESSPOOL/SEEPAGE PIT OTHER <br /> N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation V1 <br /> y� Domestic/private Drilled Dia. of Well Casing <br /> -7"- Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout _2 TO <br /> Other Other Information <br /> i y <br /> PUMP INSTALT.ATION: Contractor f --C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / / State Work Done ;{ <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFcTRUCTION OF WELL: Well Diameter, Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> !JELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information true to the be of myIknowledge and belief. <br /> r <br /> SIGNED - TITLE � <br /> DRAW T PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE Iy <br /> APPLICATION ACCEPTEDBY DATE S/ 7l <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 -GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 7;j� INSPECTION BY /°/J DATE S' <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F. a 747h <br /> 5/731M <br />