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SAN JOAQUIN LOCIII-HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.13 �5!`? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED Date Issued i L_2 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION{' Al /� � CENSUS TRACT <br /> - . - -- <br /> Owner's Name Phone Z(4 t9 <br /> Address _ 3 2- 5� �� ��Jc�.r:mac _ _ City , <br /> Contractor's Name License # z Phone �g 3 Z <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION J& PbW REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK D ' SEtJER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 7* <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /P <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / �- <br /> ___� Irrigation Gravel Pack Depth of Grout Seal S v <br /> Other A Rotary Type of Grout GL.ass <br /> Other Other Information in ew"-1,41 <br /> 7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> k PUMP UPAIR: / / State Work Done <br /> DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of , <br /> California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completio., of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ,,,t <br /> (DRAW PL T PLAN OW REVERSE SIDE) e <br /> FOR DEPARTMENT USE ONLY <br /> a P11.ASE I <br /> APPLICXION ACCEPTED BY DATE <br /> ADDITIONAL COMNEi NTS: <br /> PHASE II� U INSPECTION _ PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE ¢ �` INSPECTION BY c DATE <br /> CALL FOR A GRO INSPECTION�PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1-' 5/731M <br />