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ICL <br /> Ck? JOAQUIN LOCAL HEALTH DISTRICT <br /> Hazelton Ave. <br /> 011USE: 1641 E. , Stockton, Calif.. ^! <br /> Telephone; (209) 466-6781 N <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X5-J107p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - - /_,7 <br /> (Complete In Triplicate) <br /> ` .Application is hereby made, to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, the work herein described. ' This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4 <br /> F JOB ADDRESS/LOCATION G✓ -ted /O 14ile �dr.� i fia�� CENSUS TRACT <br /> Owner's Name5�' <br /> �'c:; F-C•� ,I'2_4' �s C Phone <br /> Address S s /6{r, L222 a=;� - City Z-1 <br /> Contractor's Name ,)q_�, �C L y License # J �3 7;�Phone qj 6~X7'6 LS <br /> TYPE OF WORK (Check) : NEW WELL /_1 DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> r PUMP INSTALLATION / / PC,MP REPAIR /! PUMP REPLACEMEld— <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 /> jC Industrial Cable Tool Dia. of Well Excavation <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 H.P. <br /> PUM£' 'REPLACEMENT• StateIYr,dV>e. <br /> Work Dome _ __- rte f,_.7 F Ls <br /> PUMP `tEPAIR: / / State Work Done <br /> G i <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 comp let' y work on a n 1, I will furnish the San -Joaquin Local Health District a <br /> WELL DRILL S REPORT of .the well an not f t em before putting the well in use. The above <br /> �nformati n is true o -the b stl�l ge and belief. <br /> SIGNED TITLE,/ C <br /> (DMW PLOT PLAN ON REVERSE SIDE <br /> j DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: f' <br /> PHASE II T, INS EC bN P SEI /F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> lim <br /> E H 1426 ;/7 <br />