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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFI E USE: 1601. E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ]� <br /> i (Complete In Triplicate) or"- - b?�O-!O <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 Saxe Joaquii <br /> County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f� <br /> JOB ADDRESS/LOCATION 1�." ,�]� r CENSUS TRACT <br /> Owner's Name R 12 . __ Phone <br /> ++ Address Ak dw t/ f f— L4 te <br /> Q. City' <br /> Contractor's Name at License � Phone,? 6.- <br /> TYPE OF WORK (Check); NEW WELL DEEPEN '/7 RECONDITION 1 / DESTRUCTION /7 <br /> PUMP• INST'AT.LATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF;WELL CONSTRUCTION SPECIFICATIONS <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 Rotary . Type of.. Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 4 <br /> � <br /> Ty'p'e of Pump . 40 - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _--PUMP-"tEPAIR-;—� <br /> DF'ZTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> .- Describe Material .and Procedure <br /> I hereby agree to comply with all laws and regulatidns 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 8 <br /> WELL DRILLE SPORT. of .the well and notify them before putting the well in use. The above <br /> information 's r to the best of my knowledge and belief. <br /> 1 <br /> SIGNED - TITLE ,J.4000^ __-•-- <br /> (DRAW PLOT PLAN1,ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE �� <br /> ADDITIONAL C0M1-tiNTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. Im <br /> N 147H /731M <br />