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' SAN JOAQUIN LOCAL_HE�LTH DISTRICT <br /> FOT'. O �Fi USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T�� <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 Jbaqu:in <br /> County Ordinance No. 1862 andsthe Rules and Regulations of the San Jona n Local Health District. <br /> 43C43 <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name <br /> ` Phone 9'31- 4_3 (64 <br /> Address k� ec <br /> City <br /> r <br /> Contractor's Name License #��Phone - <br /> TYPE OF WORK Check) : _ NEW WELL%I DEEPEN '/? RECONDITION — DESTRUCTION <br /> DESTRUCTION <br /> PUMP INSTALLATION / / PUREPAIR'/ I PUMP REPLACEMENT I�T <br /> MP <br /> Other ,/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAG91DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS w <br /> Industrial Cable Tool Dia. of Well Excavation M <br /> Domestic/private Drilled Dia, of Well Casing VJ :: <br /> Domestic/public I Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:, :.State Work Done <br /> I _ r1 r - A roxima Depth Z O f <br /> DRAT UC IO W Well Diameter w © PP r <br /> cribe Material and Procedure <br /> r <br /> J � <br /> IV-1 <br /> Jilj <br /> i hereby agree to Comply with all 1a and regulations of the San Joaquin Local Health District <br /> and the State of California pertaini g,to" or regulating well ',construction. Within FIFTEEN DAYS <br />' after completion of my work an a new well, 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 /> 4 <br /> SIGNED . , Q r TITLE • <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT, INSPECTION PHASE FINAL NSPECTION <br /> INSPECTION -BY - DATE INSPECTION <br /> —CALL.-FOR-•A•GROUT.-INSPECTION.-PRIOR .TO:GROUTING AND FINAL INSPECTION. <br /> - T, "-,)Z 5/731M <br />