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r <br /> 4E� 4 'j <br /> LOCAL HEALTH DISTRICT <br /> _OFFICE USE: ��/1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMI-' PERMIT Permit No.73- <br /> �3_s96p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued SJ J <br /> (Complete In Triplicate) <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 Ord/ina�ce i�o. �1862 and the Rules and Regulations of the San ,)oayyuin Local Health District. <br /> lda S/ Ja rT7z r� 3pFfo< -� a"l T)r' � C U•') e ae r fid/: r <br /> JOB hH�93/LOCATION ��f� f�/7 �ll :' �US TRACT <br /> Owner's Name <br /> Address City <br /> Contractor's Namefay /�/,/ LGA License /lU 'd` !�Phone �3� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ J RECONDITION /-7 DESTRUCTION /-7PUMP INSTLATION /�� PUNP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 40j- SEWER LINES PIT PRIVY 1"W <br /> SEWAGE DISPOSAL FIELD -- C6SSP60L/SEEPAGE PIT� f-OTHER �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1k3 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private JCC' 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 _ r / H.P. :5: <br /> PUMP <br /> PUMP REPLACEMENT., / / State Work Done _ <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 well and notify them before putting the well in use. The above <br /> information is tpue to the best of my knowledge and belief. <br /> . • <br /> SIGN E -s�,."�'/f .---_..._ TITLE C_.-, s ' <br /> —' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �'�' � <br /> APPLICATION ACCEPTED BY � DATE 4Zel <br /> Z2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I / INAL INSPECTION <br /> INSPECTION BYE- . DATE INSPECTION BY DATE <br /> CALL I'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> /-ro tv <br />