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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOF. OFBICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r - Telephone: (209) 466-6781 q <br /> APPLICATION FOR WELL CONSTRUCTION, DR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l) SCJ <br /> (Complete In 'Triplicpte) - <br /> Application is hereby made to the San Joaquin Local Health District fora 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 CLW <br /> of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION�LK SidI� QP_POS�T ��Cn<�'d &SJ CENSUS TRACT " <br /> Owner's Name ri4� jp—�7 gid' R: 5 r Phone jS' 771� <br /> Address C- / City <br /> Contractor's Name ' £ License li )USyPhone,�� //(� <br /> TYPE OF WORK (Check) : NEW WELL /- DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven `Gauge of Casing C. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Cogtractor A9LV-kj t 3 Ce jo C f > �U <br /> Type 'of Pump; H.P. <br /> PUMP REPLACEMENT: / /_. State Work Done <br /> PUMP 'LF2AIR: /% State Work Done <br /> DFRTRUCTION 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 we and:rnotify them before putting the well in use. The above <br /> information is true to th be E of my no4ledge• and Velief. c 6 l3(Qg <br /> SIGNED TITLE �� ± <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED:,,$X DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II aROUT INSPECTION PHASE II / JINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE - <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 N IL9A - C /71iu <br />