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SAN JOAQUIN LOCAL`I�EAL.TH DISTRICT <br /> FOS.:( .r"ICL USE* 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -FFIC- <br /> Telephone: <br /> (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 <br /> VIII ; - Date Issued <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED �-- <br /> ,i9. {Complete In Triplicate) <br /> hereby made to the San Joaquin Local Health Dist rict for a gliaricetwithnSanuJoaquin <br /> Appl(cation is Y • This application is made in comp <br /> and/0' install the work;eherein described. <br /> Coun flrdanance No�. lSb2 and the Rules and Regulations of the Sari Joaquin Local Health 'District. <br /> i �a.+ticYn ,,,,� CENSUS TRACT <br /> JOB ADDRESS/LOCATION 8 G <br /> I, IA -' Phone <br /> Owner's Name cl vW �'+'� �. <br /> city �"t c v.vfn. � w�'b <br /> Address � I o S � , �.. -Of <br /> � ti! License ���d � Phone <br /> Contractor's Name 1N <br /> TYPEOF WORK (Check) : ANEW WELL l,7 DEEPEN / I RECONDITION_/ / DESTRUCTION I? <br /> I ''PUMP INSTALLATION / / PUMP REPAIR I / PUMP REPLACEMENT �� <br /> "Other J% Qq <br /> IT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TAGvK SEWER LINES <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> N TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial I� Cable Tool. Dia. of Well Excavation <br /> rivate Dia. of Well Casing <br /> 4JDrilled <br /> T -------- <br /> Domestic/private Driven Gauge of Casing t �- <br /> Domestic/public <br /> ilk Irrigation Gravel Pack Depth of Grout Seal o <br /> Other .o - Rotary Type of Grout C- <br /> �� Other Other Information ' <br /> P 141 INSTALLATION: I ContractorPUMP <br /> H.P. <br /> ii Type • P <br /> pUMP REPLACEMENT: / State Work Dome _ <,�; <br /> State Work Donef� `� n� <br /> 'tEPAIR-: II -/ <br /> PUMP V <br /> Approximate Depth _ <br /> I DTRUCTION OF WELL: '! Well Diameter <br /> II Describe Material and Procedure <br /> 1ulations of the San Joaquin Local Health District <br /> d re <br /> i 11ihereby. agree to comply with all laws an E Within FIFTEEN <br /> y and the State of California pertaining -to or r <br /> I willegu�furnish ethe cSan tJoaquin,Local Health District <br /> after completion of my work on a new r <br /> I WE.-L DRILLERS REPORT11of the well and notify them before putting the well in use. The above <br /> 1. id1forma true. to the bes of my knowled a and belief. <br /> t =1 TITLE <br /> SIGNED (.DRAW PLO PLAN ON REVERSE SIDE) <br /> !i FOR DEPARTMENT USE ONLY <br /> P; ASE I 11 DATE <br /> 1 APPLICATION ACCEPTED BY <br /> ADDITIONAL COMidENTS:' PHASE i / INAL INSPECTION <br /> PHASE YI GROUT INSPECTION INSPECTION BY AT <br /> IN BY DATE / <br /> CALL FOR Ar GROUT41NSPECTIONLLPRIOR -TO GROUTING .AND FINAL INSPECTION. 5f7 3 IN <br />