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V' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTCalif, <br /> claStockton, <br /> POI. OFFICE USE"• I6Q1 E. Hazelton Ave• � 466•-6781 <br /> Telephone: (209) PERMIT permit Na. �,�=9�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUM3' 7th <br /> THIS PERMIT EXPIRES 1 YEAR <br /> FRAMDATE ISSUED Date Issued <br /> a <br /> (Complete In Triplicate) permit to construct <br /> This application is made in complianceile���hth San Dis�rict�n <br /> Application is hereby made to the San Jodaquin Local Health District for Local <br /> District- <br /> and/or install the work herein described. - <br /> Ordinance No. 1862 anthe Rules and Re u tions of the San Joaquin01 S TRACT <br /> county a- 1 <br /> JOB ADDRESS/LOCATION ' Phone ��"-- - <br /> owner's Name CitWAW <br /> Address 4 Phone <br /> IF ALicense #e2 <br /> Contractor's Name <br /> DEEPEN I I RECONDITION_/_/ DESTRUCTION l_T <br /> TYpg OF WORK (Check) : NEW WELL ,L.ME REPAIR / / PUMp REPLACEMENT 17 <br /> PUMP INSTALLATION / / <br /> Other / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK D CESSPOOL/SEEPAGE PIT OTHER ` <br /> SEWAGE DISPOSAL FIELD _ <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial Drilled Dia. of Well Casing J <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public , Depth of Grout Seal <br /> Irrigation Gravel Pack p <br /> Rotary Type of Grout <br /> Other <br /> OtherOther Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: 0/ State Work Done <br /> PUMP REPAIR:!/ State Work Done <br /> Approximate Depth <br /> DFGTRUCTION OF WELL: Well <br /> rial and Procedure <br /> rict <br /> I hereby agree to comply with all laws and regulations owe .construction.f the San Joaquin LoWithin cal aFIFTEEN tDAYS <br /> and the State of California pertaining to or regulating <br /> after completion of my work on a new wells I will furnish the San Joaquin Local Health District <br /> b <br /> WELL DRILLERS REPORT of the well and notify them efore-putting the well in use. The above <br /> informs is e o the best of my knowledge and belief. <br /> TITLE .----- <br /> ;s SIGNED (DRAW PLOT' PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT 135E ONLY <br /> PHASE I ` DATE 7 <br /> APPLICATION ACCEPTED. BY _eAi4w� <br /> ADDITIONAL COMMENTS: PRASE III/FINAL INSpECTIOP' <br /> PHASE II OUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5 L <br /> F W 1L7h <br />