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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> T Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6-.3 4a P <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 Focal Health District. <br /> JOB ADDRESS/LOCATIONS CENSUS TRACT <br /> r <br /> Owner's Name AV iPhone <br /> Address City ' <br /> Contractor's Name La� License ` � Phoney�0­10'41V" <br /> TYPE OF WORK,(Check): NEW WELL / / DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PL'M#' REPAIR / / PUMP REPLACEMENT <br /> Other/ J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information f <br /> L <br /> PUMP INSTALLATION: Contractor <br /> - <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work Done l! <br /> PUMP `tEPAIR: / J State Wo one <br /> .DFI-TRUCTION OF WELL: Well Diameter j 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED Q-(f �`/{v �pTITLE e , <br /> DRAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ' <br /> PRASE I �{ <br /> APPLICATION ACCEPTED .BY G DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II kROUT INSPECTION PHASE III FINAL INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY DATE 6 <br /> CALL,F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> V. -34 1A94 r /nom ._. <br />