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w L <br /> SAN JOAQUIN LOCAL .MALTH DISTRICT <br /> FOt. <br /> OFFICE USE: 1601 E. Hazelton A.ve. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 93W <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 Joaquin. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. health Dis4rict. <br /> JOB ADDRESS/LOCATION /UG a1G CENSUS TRACT <br /> Owner's Name 26 ;� Phone <br /> Address 3 City <br /> Contractor's Name ,r License # hone } � <br /> f TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /-/- DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR Z PUMP REPLACEMENT /-7 1 <br /> Other J / <br /> t 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 D'iA:- of Well Excavation <br /> Domestic/private. _... .. . . ..... Drilled - :...-..Dia, .of..Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack " "`Dep'th- (if Grout Seal <br /> Other. . . .. . ...... .,Rotary. :...-.. .. -Type of Grout <br /> Other Other Information <br /> s <br /> PUMPINSTALLATION: <br /> ATION: Contractor <br /> Type of Pump ... H.P. <br /> PUMP REPLACEMENT . <br /> ' / { State Work.Done <br /> PUMP 'ZEPAIR;. / Stag Work Done <br /> 4: <br /> E <br /> ,DFRTRUCTI.ON OF 'WELL.: Well Diameter Approximate Depth <br /> . .Describe Material and Procedure. <br /> hereby'agr'ee "to' comply with all Taws 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 Joaquin Local Health District a <br /> WELL DRILLER5; REPORT'.6f the well And notify 'them Before 'putting the well in use. The above <br /> information-is true:.to. the.best .of.-my know dge .and . e <br /> SIGNED" 'S�2d <br /> . .. .;.. ... . ._ <br /> (DRAW -. O .. L ON REV E .SIDE) <br /> POr <br /> ;. ... <br /> DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY ... DATE <br /> ADDITIONAL CO;9MENTS: !!!" <br /> :PHASE II GROUT INSPECTION 14/"NAL INSPEC <br /> - <br /> INSPECTION-BY. :..... ....... ..:....DATE.. ;.. . .:..... .: . INSPECTION .B ATE <br /> JA <br /> CAI.I.d�i*4 �A6Rt?i �SNSPEGT�fliS�,F�tICa .,..T.O .GROUTING_.-AND._EINAL.INSP N . .�4 _.... _.,_. <br /> E H_.1426_ 5/7 <br />