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L SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> FOk.:Ok k"ICE USli: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Z / <br /> P <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issue 7q- <br /> J (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Re ulatione of the San Joaquin 'Local. klenith .Dis�rict. <br /> JOB ADDRESS/LOCATION I N s�N CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Al. City <br /> Address f ..� q'`,` j r <br /> License #p2_&o9S` Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELLY DEEPEN '/ / RECONDITION /—/ DESTRUCTION /7 <br /> PUMP ;INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT. / T <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 SPECIFICATIONS <br /> Industrial <br /> 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 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> '] :- #"S tate Work Done <br /> PiSMP REPLACENd;NT: I / _ <br /> kr PUMP 'tEPAIR: / State Work Done <br /> pFgiRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> a Describe Material and Procedure <br /> I <br /> I hereby agree to comply with all laws and regulations of the San. Joaquin Local Health District <br /> and the Stare 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. DR �RS REPORT of the well and notify them before putting the well in use. The above <br /> informa 'on 1 true o thbest o my knowledge and belief. <br /> f <br /> _P SIGNER TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 'FOR DEPARTMENT..USE ONLY �L <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY _�iyJ?�f <br /> f <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPEC'TIO <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY /for ,^ DATE J- x.37 y__ INSPECTION BY DATE l ae3 .7J- <br /> - CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. 7 im <br /> - 1 I-/ - -- <br />