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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. OF ICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> i _- <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 rade to the San Joaquin Local Health District for a permit toconstYuct <br /> and/or install the work herein described. This application is made ixi compliance with San Joaquin <br /> County Ordinance No. 18 2 and the Rules and. Regulations of the San Joaquin Local Health Dishric.t. <br /> °Z34/95- CENSUS <br /> JOB ADDRESS/LOCATjITRACT <br /> ON <br /> Owner`s Name / // /��f3 O ��� _ PhoneJ'�S=SSS Z R <br /> Address © City <br /> F` ._Goutraetor r s-:Name_ - _ _icense �Phone <br /> TYPE OF WORK (Check) : NEW WELL �EEPEN / / RECONDITION / / DESTRUCTION /? <br /> PUMP; INSTALLATION / / PUMP REPAIR / '/ . PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERSLTNES PIT PRIVY y . <br /> SEWAGE DISPOSAL"FIELD � � "'`CESSPOOL/SEEPAGE PIT . OTHER` _ a <br /> INTENDED USE TN�'PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> :�Dome'stic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 'F Gravel Pack Depth of Grout Seal <br /> Other. . ::�Rotary Type of Grout f <br /> Other ' Other Information— <br /> PUMP <br /> nformation PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done} '! <br /> PUMP 'tEPAIR: "/ State Work Done <br /> ' ;,DFgTRUChbN OF WELL: Well'Diameter Approximate Depth <br /> -*''Describe Material and Procedure <br /> I hereby-agree to comply with 41-1 laws and regulations of the Sari Joaquin Local Hdflth District <br /> . and the State of Caaiornia pertaining to or regulating well 'construction. Withib- FIFTEEN DAYS <br /> after completion of-my work on a new well, .I w 11 _furnish' t.he. San Joaquin Local Health District a <br /> CELL DRILLERS REPORT "of the.well and notify them before putting the well in use. The above <br /> i information is .true to the best of my knowledge and belief. <br /> r <br /> a <br /> SIGNEDr c �m�lsy TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> y OR TMENT'USE ONLY' " i <br /> PHASE I _ 7 <br /> APPLICATION ACCEPTED . DATE '� / <br /> ADDITIONAL COr . <br /> I OUT: INSPECTION" P 'SE I / NAL INSPECTIO <br /> INSPECT DATE -" INSPECT OI� BY DATE <br /> CALL FOR A GROUT INSPECTION PRI0R TO ROUTYI3G AND FINAL INSPECTION. ` <br /> E H 1426 5/73_lM =. <br />