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SAN JOAQUIN LOCAL HEALTH DISTRICT 5u� cm Y1 vz// <br /> I.0) .OFFICE USE. V 1601 E. Hazelton Ave.. , Stockton, -Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT ,-EXPIRES 1. YEAR FROM DATE ISSUED Date Issued a-,2o-7¢ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit toyconstruct <br /> and/or install the, work herein described. ' This application is made in compliance with San Joaquin <br /> County OrdinanceNo-.,-1662rand the Rules and Regulations ,of the San Joaquin Local Health District. <br /> y <br /> JOB ADDRESS/LOCATIONe/q .b F' I#vAA S,4 CENSUS TRACT <br /> Owner's Name C, Phone <br /> Address -- . ..�.. City , <br /> Contractor's Name. 46"Al License # / y,��Phone 24A•'7G7Z <br /> TYPE OF WORK (Check): NEW -WELL / / DEEPEN /_� RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / PG'MP REPAIR '/ / PUMP REPLACEMENT /_71< <br /> Cl <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC T&4K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE. TYPE OF WELL CONSTRECTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia, of Well Casing <br /> & at I /public Driven Gauge of Casing <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 �S H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP: / / State Work Done T,/ p G/ .I�LG /,17 °i�� !h „jI euj mf/ s <br /> ,DF'qTRUCTION 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 REPOkTT of the 'well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge belief. <br /> SIGNED <br /> Alt 4(DNW PLOT .PLAN ON REnR SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY - DATE _i l 1_Z f <br /> ADDITIONAL COMMENTS.: <br /> PHASE II ZOUT INSPECTION PHASE IXjZNAL PECTIO <br /> JN <br /> INSPECTION BY - DATE INSPECTION BY E <br /> CALL FOR A GROUT­INSPECTIONmPRIOR TO GROUTING AND FINAL'INSPECTION. <br /> 1P u lAhr r P7 j... <br />