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SAN JOAQUIN LOCAL HEALTH DISTRICT1� <br /> f. .4 <br /> EOL OFFICE USE: <br /> 1601 E. ' Hazelton Ave. , Stockton, Cali -7 S-L!a I � <br /> Telephone; (209) 466-67$1 Permit No. 3 <br /> ---' APPLICATION FOR WELL CONSTRlICTIDN OR PUMP PERMIT ;i <br /> d� d Date issue �`:Lk- 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE •ISSUED ----—� <br /> 1�e <br /> (Complete In Triplicate) emit to construct <br /> Application is herebymato the San .ToaquThisaapplicationBistmade iict n compliance with San Joaquin t' <br /> and/or install the work herein described. application <br /> County Ordinance No. 186x2 and <br /> the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT ' tI <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name __yeje�Lt& <br /> City <br /> f Address <br /> License # Phone <br /> Contractor's Names �. , . <br /> 164 WELL <br /> TYPE OF WORK (Check) : 64 WELL / DE}�P� / / RECONDITION_I�( DESTRUCTION / T <br /> PLIMP INSTALLATION pbW REPAIR -I / PUMP REPLACEMENT <br /> ;',Other <br /> SEWER LINES _ PIT PRIVY <br /> SPO <br /> DISTANCE TO NEAREST: SEPTIC TANK CESOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD O <br /> INTENDER U5E TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4� <br /> Industrial Cable Tool Dia. of 'Well Excavation �' ' <br /> Drilled Dia. of Well Casing <br /> X:Domestic/private. Driven Gauge of Casing <br /> Domestic/}public <br /> � . _____..- Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Other Rotary Type of Grout <br /> Other Ocher Information <br /> ___ _ <br /> F <br /> PUMP INSTALLATION: ' Contractor ElomesGic Service H.P. <br /> r <br /> Type of Pump 1 H.P. Sub <br /> PUMP REPLACEMENT' �i' / State Work Done <br /> St-ate -Work'=Done'. <br /> L,.-P'iiMi� "iEFAT�t:-- �" . . a� l_._.,.I a_......- <br /> r _ Approximate Depth <br /> ,DFgTRUCTION OF WELL: j Well Diameter <br /> Describe Material and Procedure <br /> ions of i <br /> r c. <br /> I hereby agree to comply witheall <br /> law an oregegulatiula ng we11�'construction.San oaquin LoWithin aFIFTEEN tDAYS <br /> ailc the State of Calmarnia p g <br /> after completion of my work an a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ;.6f 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 /> '_ .E , s�J TITLE <br /> SIGNED '� �C a'`'�' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT U E ONLY <br /> PHASE I # ' DATE VSO J 7Z <br /> APPLICATION ACCEPTED,!BY <br /> f ADDITIONAL CD�NTS: � PHASE III/FINAL INSPECTION <br /> CHASE I GROUT INSPECTIQIL INSPECTION BY DATE q a-�' - 713-- <br /> INSPECTION BY :II DATE <br /> CALL FOR A GROUTINSPECTIONPRIOR TO GROUTING AND FINAL INSPECTION. 5/731M/?31M <br /> E H 1426 <br />