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SAN JOAQUIN- LOCAL HEALTH DISTRICT <br /> Oi. OST SCE USE: , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466W-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ������ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued f,2 <br /> i (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 Joaqui.t <br /> County Ordinance No. 1862 and the Rules and gul tions of the Sacs Joaquin Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION r �. } ! . 4'� �/ CENSUS TRACT S 1 <br /> Owner's Name 9AftA, a Phone �T 7 f <br /> Address �` City . . <br /> Contractor.''s.Name. - "'� ` :� V:License. �� -� hone ;3 <br /> TYPE OF WORK (Check) : NEW,WELL / / DEEPEN / ( RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST TION / / 'PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other f-1 — <br /> ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LIDS PIT PRIVY <br /> SEWAGE DISI' SAL I'IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE k TY E OF WELL CONSTRUCTION SPECIFIL&YIONS <br /> C Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> df <br /> Domestic/public Driven Gauge of Casing dr <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Other ,Y Rotary Type of Grouter-_ _ <br /> Other Other Information - - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUS' REPLACEMENT: f I State, Work_'Done_ <br /> PUMP `tEPAIR: /-7 State Work Bone <br /> { <br /> ' ,DFCTRUCTION 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 we 1 and notify them before putting the well in use. The above <br /> information true o the e t of m knowledge and belief. <br /> SIGNED TITLE <br /> wW4&UT PLAN ON REVERSE SIDE <br /> w R DEPARTMENT USE ONLY <br /> PHASE . Cu <br /> APPLICATION ACCEPTED .BX �/ � -- - - -- DATE J off- '-,If <br /> -70 <br /> ADDITIONAL.'COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE LII/F INSPE TI <br /> INSPECTION BY DATE INSPECTION BY DATE T <br /> CALL FOR-A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H IA26 5/731M <br />