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SAN JOAQUIN LOCAL T;EALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued - 1Z 77! <br /> (Complete In Triplicate) 2q7-1 [ca –06 <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 /> VZ C', <br /> JOB ADDRESS/LOCATION l CENSUS TRACT <br /> Owner's Name IGAI.1 S -___ Phone "09!:20- <br /> - <br /> Address City , 6.91104/ -- <br /> Contractor's Name . Rw - License #" Phone <br /> TYPE OF WORK (Check) : " NEW-WELL / / •DEEPEN '/=/ =RECONDITION IST-.DESTRUCTION -/7 _.. �. <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST. SEPTIC TANK__...—_- SEWER LINES PIT PRIVY `v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial :F Cable Tool Dia. of Well Excavation <br /> Domestic/private�• Drilled Dia. of Well-Casing <br /> Domestic/publ.ic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout,Seal <br /> Other " Rotary Type of Grout - k <br /> -' Otlier Other Information <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / . / State Work Done <br /> PUMP REPAIR: /State Work Done <br /> j tSTRUCTION Op WELL: "-Well'Dia�e-ter "' `_ _ - 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 FIF'T'EEN DAYS <br /> after completion of my work on 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 /> G information is true to the best of my knowledge and belief. `' <br /> SIGNED TITLE _ J -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE -z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ,� DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426_ 4172 1M� <br />