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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£_:OFFTCI USE 1601 E. Hazelton Ave. , Stockton, Calif. 7' <br /> Telephone: (209) 466-6781 <br />'F -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3- �5�3 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 1: z 7.73 <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, District. <br /> ON CENSUS TRACT <br /> JOB ADDRESS/LOCATI ,Fj '�. /7I�!%L°�'ri — <br /> Owner's Name z2yn. _&& , _ Phone <br /> City , <br /> Address <br /> q License # / <br /> Contractor s Name p ` Phone , <br /> TYPE OF WORK (Check) ; - NEW WELL /P"'DEEPEN '/ / RECONDITION /_/ DESTRUCTION /=T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TALK ��_ SEWER LINES PIT PRIVY <br /> y '.SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E <br /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / O <br /> H <br /> Domestic/private grilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ( _ Irrigation Gravel Pack Depth of Grout Seal S6 f <br /> j Other �f/ Rotary Type of Grout <br /> t Other Other Information 1 <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 71EPAIR: /% State Work Done <br /> i <br /> DF�TRUCTION OF WELL Well Diameter Approximate Depth <br /> A. Describe Material and Procedure <br /> 3 , <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 we11''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wi11 furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> '$ information is, true to the b t of my knowledge and belief. <br /> LSIGNEb TITLE <br /> '_ {DRAW OT PLAN ON REVERSE SIDE <br /> {� t OR DEPARTMENT USE ONLY <br /> i. PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY I DATE , G 7 <br /> CALL FOR;;A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL II3SP ION. <br /> W 1 L9ti 5/731M <br /> F <br />