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f <br /> VRFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, <br /> VCalif. <br /> ! Telephone: (209) 466-6781 <br /> R APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued, <br /> (Complete In Triplicate) <br /> i Application is hereby trade to the San Joaquin Local Health District for- <br /> a permit to- construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> III, .County Ordinance No. 1862 and the Rules a d egulations of he San Joaquin Local Health District, <br /> ` JOB ADDRESS/LOCATION <br /> CENSUS TRACT . <br /> Owner's Name <br /> I <br /> Phon '. ' <br /> Address tl } <br /> ' Ci k <br /> y <br /> i Contractor's Na License <br /> �' !d�Phone,�T' 7 Q 32 C/ <br /> TYPE OF WORK (Check): NEW WELL #_';f DEEPEN /_7 RECONDITION -� s <br /> PUMP INSTALLATION /? DESTRUCTION %7 <br /> / UMP REPAIR / / PUMP REP <br /> Other. /:/ LACEMENT 1—f <br /> DISTANCE TO NEAREST: SEPTIC TANK dEWER L NE5 <br /> 111' <br /> SEWAGE DISPOSAL FIEL �CESSP00L/SEEPAGE PIT <br /> D'Qs <br /> OTHER -•-�� <br /> INTENDED USE TYPE OF WELL <br /> Industrial . CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> ��� Omestic/private . Q <br /> Drilled ; <br /> 4> Dia. of Well-Casing <br /> Domestic/public _, Driven Gauge of Casing <br /> Irrigation - Gravel Pack De�_th <br /> Other of,G"rout S 1 ' <br /> ~.CC:Aotary Type of Grout � �• , <br /> Other Other I <br /> �� tiformation <br /> PUM "' TALLATION: Contractor <br /> it Type of ump <br /> _ v H.P. <br /> PUMP REPLAC -'� <br /> �T= / / State Work Done •'�...� f` i`'ti, <br /> PUMP REPAIR: /_77 State Work Done �F ` <br /> ESTRUCTION OF WELL: '. Well Diameter <br /> Describe- Material}and Procedure " 'AP,P:e oxiate Depth <br /> I hereby agree to compljr with a11�Jawsand•,regulatians'of the San dbaquin Lacal Health District. <br /> and the` State,•of California pe.rtainiitg,Co or regulating well construction. <br /> after comPletion of my work on a now w li, I will fWithin FIFPEEN DAYS <br /> urn 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 /> infor tion is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> W PLOT PLAN ON REVERSE SID�� <br /> ,BASE I '4 ,FOR DEPARTMENT USE ONLY <br /> ; <br /> �P CATION ACCEPTED BY <br /> IDDITIONAL COMMENTS. DATE <br /> 11 <br /> PHASE II GRO INS P CTION ` <br /> 'NSPECTION By DACE �' P SE III F NAL INSPECTI N <br /> INSPECTION BX - DATE <br /> CALL FOR A GROUT•INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 , <br /> i. /72 IM '' <br />