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^� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOt.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3-.r 3 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 compliance with San Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health nistric <br /> JOB ADDRESS/LOCATION 7�SCj _Sr,)g)d2 _- �� LL b �� IACD, CENSUS TRACT <br /> Owner's Name Vo eNj,q S 7_2,6(Z Phone <br /> Address D P, City flea/ ,s TO <br /> Contractor's Name '`i Q„ Is„yl�d.�/ � ,� License #,,'171�0 shone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /1f/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <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 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 %Q 4) - z) <br /> Type of Pump �',.� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: /_7 State WorkkDDoneA <br /> ,DFRTRUCTION 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 DAY <br /> after completion of my work on a new well, I will furnish the.-San Joaquin Local Health District <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to th best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DAM PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> Z, /7 <br /> APPLICATION ACCEPTS Y DATE <br /> ADDITIONAL CO <br /> P I O P C P S II INSPEC ON <br /> INSPEC ION BY ATE INSPECT ATE <br /> CALL FOR A GROUT I PECTI:ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> n IT 1 1.•l 1 r� /7'7.-. <br />