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'SAN SJ{1AQUZ•N Lt3CAL IIEALT D Sx jt <br /> 9:OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Sart Joaquin <br /> County Ordinance No. 18622 and the Rules <br /> and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION l/�' �7���L» CENSUS TRACT <br /> Owner's Name Xens;e, Px;vv e Phone <br /> Address 'L�"" / /� C'_l / �/' •� L City <br /> Contractor's Nam L U 1�-1 -3 �- License de J 3� Pham <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / f RECONDITION /_/ DES'T'RUCTION /-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 SPECIF'I'CATIONS <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 Seal <br /> Other ^� E Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump2 H.P.- <br /> PUMP REPLACEMENT: �' State Work <br /> PUMP `tEPAIR: /7 State Work Done <br /> .DFGTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F 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 ]SAYS <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 true to the best of my knowledge and belief. <br /> r <br /> SIGNED TITLE )W <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PhASE i FOR DEPARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY DATE -f <br /> ADDITIONAL COMMENTS; If <br /> PRASE II GROUT I SPECTION PHASE III/]SINAL INSPECTION <br /> INSPECTION..BY DATE INSPECTION BY DATE ^- <br /> CALL FOR INST?ZCTION-�PRIOR TO GROUTING AND FINAL .INSPECTION. <br /> E H 1426 fN C /7-2,u <br />