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zlo," - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave:. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTgUCTION OR PUMP PERMIT Permit No. ` <br /> FROM DATE ISSUED _/7/ <br /> THIS PERMIT EXPIRES 1 YEAR - p ` <br /> - -, Date Issued <br /> (Complete In Triplicate)' <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. 3862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/EC1L'NIO-kZ,19 <br /> z/J CENSUS TRACTf <br /> Owner's Name <br /> Phone <br /> Address y <br /> City � <br /> Contractor's Name }*� A y, iS License <br /> -E�� Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN RECONDITION DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 ^ <br /> Other / / o - <br /> ---- - <br /> DISTANCE TO NEARES'T:�""`SEPTIC"`TANR'-�� �WER LINES PIT P32IVY <br /> SEWAGE �ISPOSA, FIELD CESSPOOL/SEEPAGE (PIT1 01 OTHER � } <br /> f y.. <br /> INTENDED USEL TF W CONSTRUCTION SPECIFICATIONS 4 <br /> _ 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 Seial <br />_- Other Rotar <br /> Rotary <br /> Type o€ Grout -_ <br /> Other Other Information - I <br /> PUMP INSTALLATION: ; Contractor7ke <br /> � / <br /> Type of Pump H.P. ?, <br /> L.. <br /> PUMP REPLACEMENT: / / State Work Done3 <br /> q F <br /> VA I 1 <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> fL�-Approximate Depth P <br /> Describe Material and Procedure -- <br /> C hereby agree to comply with all laws and regulations of the San Jo quin 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 I <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true; to the best of my knowledge and belief. <br /> F <br />;IGNED �p <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br />,PPLICATION ACCEPTED BY <br /> DDDITIONAL COMMENTS: DATE j 7 <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> NSPECTIDN BY DATE 7.. INSFECTION,BY DATE . _ -7 <br /> CALL FOR A. GROUT' INSPECTION PRIOR TO GROUTING:Ap_FjNAI,-1NS,pECTIO . <br /> 1M <br />