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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.':OFFICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �s=1a <br /> THIS PERMIT EYPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the -Sa&'Joaquin Local Health District for a permit to construct <br /> �v <br /> and/or install the work herein descr, ibed. ' 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 alp 3�$r /1- P R A6t`f CENSUS TRACT <br /> Owner's Name 17 S '3C' Phone Y <br /> r <br /> Address �0 3 /L 'T City - <br /> Contractor's Name License &RIk L7 fPhone 3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PL`MP REPAIR/ / PUMP REPLACEMENT /7 <br />'F <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 /> r Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public j 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 /> - <br /> Type'. of Pump H.P. <br /> PUMP REPLACEMENT: / IState Work Done <br /> PUMP UPAIR: j j State Work Done <br /> #j DFQTRUCTI0N OF WELL: Well Diameter Approximate Depth <br /> 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 State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new veli,- I will furnish the San Joaquin Local Health District a <br /> WELL 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 /> SIGNED44,;r LJE- ?m ITLE <br /> s€ W PLOT ON REVE SIDE) <br /> +� <br /> F DEPARTMENT USE ONLY <br /> PRASE I �--. <br /> j 46 <br /> APPLICATION ACCEPTED BY �` DATE /'�Gr75_ <br /> ADDITIONAL COUNTS: <br /> i <br /> PHASE II L IONP IN <br /> INSPECTIO <br /> INSPECTION BYDATE INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> L* 7r 't1,7r 5/731M <br />