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tics SAN JOIj4U 'LOCAL HEALTH DISTRICT <br /> l FOL,' 11{ICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> "- Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-fit - � <br /> V� <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.wiCti San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ J �D " e i _ CENSUS TRACT , <br /> Phone f <br /> Owner's Name -- <br /> Address �r1.m.� City ' ' <br /> Contractor's Name <br /> License Phone Pad96 <br /> r <br /> TYPE OF WORK (Check) : NEW w' ELL 'PV DEEPEN '/ / RECONDITION / DESTRUCTION /? <br /> -7 <br /> PUMP INSTALLATION pumP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> - s <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation / P <br /> A-1-Domestic/private k Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing <br /> Irrigation I, ' Gravel Pack Depth of Grout Sea! <br /> _ Rotary Type of Grout 1&&e:± <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor � . <br /> r Type of Pump �• H.P. 2.i f <br /> 1 { <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'tEPAIR: / /� State Work Done _ <br /> S DF-,TRUCTION 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 /> I after completion of my work on a new well., I will furnish the. San Joaquin Local Health District � <br /> 4 WELL DRILLERS REPORT o well and notify them before putting the well in use. The above <br /> information is true o t dies o y kno . edge and belief. <br /> SIGNED TZTL <br /> (DRAW PLOT 'LAN ON REVERSESID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE 1 <br /> APPLICATION ACCEPTED .BY DATE r <br /> ' ADDITIONAL CO*iMENTS: p S /FIN INSPECTION <br /> PHASE II GROUT INSPECTION f DATE <br /> INSPECTION BY DATE INSPECTION B <br /> - CALL FOR A GROUT INSPECT ON PRIOR TO G OUTING AND FINAL INSPECTION. <br /> 5/731M <br />