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`� `• SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> T-6—r-OFFICE USE: 1.601. E. Hazelton Ave. , Stockton, Calif. i <br /> F- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �1111-.&/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;i 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 ;lcompliance with San Joaquin <br /> County Ordinance No. 1852 and the Rules and Regulations of the San Joa uin Local Health District. <br /> � <br /> JOB ADDRESS/LOCATION f <br /> j- n A 6) /h r :i CENSUS TRACT <br /> Owner's NameI_(,�(��� �aM�n.S - �LII^f/5 l PuJ/5-- II Phone <br /> Address �o h� �S -,/��'�(t!'! �� City . . Xa #L04 <br /> _ _ _ <br /> Contractor's Name License 46 �L`16. ? PhoneS��51 .3 1 <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN '/—/ RECONDITION /—/ DESTRUCTION /-7PUMP INSTALLATION /t-�'_PUMP REPAIR/—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TLXK SEWER LINES PIT PRIVY ; <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing,i -- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seall <br /> Other ✓ Rotary Type of Grout <br /> - 1/ Other 2"e _ Other Information 7� <br /> PUMP INSTALLATION: Contractor I' <br /> 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> i <br /> PUMP 'tEPAIR: J / State Work Done J' <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Dep h <br /> Describe Material and Procedure _ <br /> f <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 G <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DMW gOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ,I <br /> PHASE II GROUT INSPECTI S •✓ g(dl PHAS I FINAL INSP CTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. I! �+ <br /> V v lAgK &./'7'2 <br />