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SAN JOAQUIN LOCAL HEALTH 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 <br /> �9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued el �-�j� <br /> (Complete ,In Triplicate) <br /> Application is hereby made to the San Joaquin ,Local Health District for a .permit to coastruct <br /> and/or install the work herein described. - This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1662 and the Rules and Regulations of the n Joaquin Local. Health District. <br /> 5 <br /> .TOB ADDRESS/LOCATION t Zt CENSUS TRACT, <br /> r <br /> owner's Name _Ij r , �/'k_AnpS' /Z1 Phon � --c2 <br /> > ` <br /> Address T l211 . , �CAA, 4422e aD6 ��/ City , <br /> Contractor's Name (�(J yC License #,-jjPhone <br /> TYPE OF WORK (Check): NEW WELL 7/ DEEPEN '/—/ RECONDITION / _ <br /> / DESTRUCTION / <br /> PUMP INST TION PC`M1' REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "r <br /> Industrial Cable Tool Dia. of Well Excavation ff <br /> Domestic/private Drilled Dia. of Well Casing �..., <br /> Domestic/public Driven Gauge of Casing 1' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP T2EP.AIR: f j State Work Done <br /> ,_DFsTRUCTION OF WELL: Well Diameter 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 FIFTEEN 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 /> inforti is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE-1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I I/FI INSPECTION <br /> INSPECTION BY DATE INSP CTION BY DATE -S' 74 j <br /> a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> V U 7400 if /7Z-j,. i <br />