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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -ROWOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 A <br /> 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T4-I./-Wap ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued z4- ;,q- i <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 Sart Joaquin <br /> County�r��ance No. 1862 a Rules a ula t ons of/4e San Joaquin Local Health District. <br /> ... ;F <br /> JOB ADDRESS/LOCATION ' - /Al Sr4 ,CENSUS TRACT t <br /> Owner's Name D U [O Q.2c) / a/ Phone <br /> Address C=674-ok 05. City <br /> Contractor's Name v PAO/. License #, SalG► hone ?--defy # <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> '* Other <br /> DISTANCE TO NEAREST: SEPTIC TA1NK 0%&-f`SEWELINES �-.fk'IT PRIVY <br /> SEWAGE DISPOSAL FIELD ESSPOOL/SEPAGE'PIT HER <br /> INTENDED USE /TYPE OF WELL CONSTRUCTION SPECIFIC ONS f <br /> ' .�I,,�ndustrial _` , Cable Tool Dia. of Well Excavation 4 <br /> (. i5omestic/private Drilled Dia. of,Well Casing # <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -Gravel Pack Depth of Grout SalO 7 Cr? 4 <br /> Other - -- Mary Type of Grout <br /> Other, Other Information S i. C . ` <br /> PUMP INSTALLATION: Contractor' <br /> Type of Pup <br /> PUMP REPLACEMENT: / State Work`Done <br /> PUMP TZEPAIR: / / State Work-Done ►t, Te y <br /> ,DFCTRUCTION OF WELL: Well Diameter _ t _ Approximate Depth 4 <br /> Describe Material androcedure <br /> r <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 well,, I will furnish the San Joaqui�,Local Health District a r <br /> WELL DRILLERS REPORT of the well and notify them before putting the well 'in use. The above <br /> informa 'on is true to the best of my ge and belief. '`o' z <br /> f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP'TEDIBY,� .' S DATE 1421117 <br /> ADDITIONAL COM IE 'TS. '�J .5Z' <br /> ` ''PHASE II GROUT INSPECTION F PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY JX4 DATEZip— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ---E H 1426 _e 4 j e ' `1 c , r 5/731M <br />