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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fof_,,OFPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-.,��1G� <br /> THIS PERMIT. EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued <br /> 3 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Nand/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 Iteal,th Dittricr. <br /> JOB ADDRESS/LOCATION If1���4� J - ��/� MA)N 4YF -- - - CENSUS TRACT �7 <br /> __ 11 P <br /> Owner's Name !�Y Phone <br /> Address City <br /> Contractor's name f . License #� QA ZPhoile5-14 C72-75 <br /> TYPE,QF.-WORK—(Check-)-:- -NEw--WF, . -•�.W.DEEf'-EN�-/. / RECONDITION ;L/.-�-DESTRUCTION /? � <br /> PUMP IN TION / / PUMP REPAIR / / PUMP REPLICEMENT /I <br /> _ Other I <br /> DISTANCE TO NEAREST: SE1?T..IC TANK LSEWER LINES "r-PIT PRIVY F i <br /> r SERGE DISPOSAL FIELD I f1I CESSPOOL/SEEPAGE PIT_A75Nr_. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ! Industrial. able Tool € Dia. of Well Excavation 2 1/ i <br /> I Domestic/private rilled Dia. of Well Casing +r <br /> f Domestic/public Driven Gauge of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal _21 1 <br /> Other Rotary Type of Grout C' <br /> Other Other Information A,A`NrtECA, <br /> r t <br /> PUMi? INSTALLATION: Contractor <br /> i ? Type�of Pump <br />` PUMP; REPLACEMENT: / / , State Work Done } <br /> — .. ,.,..._ - - _ _ _ _�' .!w..-.,,�-•..mss. ,..+r.� 1 !�.. ; = - <br /> MU "EPAIR: <br /> r 3 <br /> DF-TRUCTIO'N OF'f�LLL: Well Diameter __- _ `5, ._ ^,,-4pproximate Depth- <br /> T Describe Material and Procedure t. L:-'; <br /> i <br /> I hereby agree to comply with all laws and regulations of-the San Joaquin Local Health� District <br /> andithe State of California':pertaining to or regulating well ''construction. Within' FTFTEEN 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. Til above <br /> `4 <br /> information is true tathe est of�Yknowledge and belief' <br /> SIGNED - - - �, _..--, -`-=UTL'E. <br />- DRAW-PLOT-LOT <br /> FOR DEPAP <br /> TMENT USE ONLY <br /> PHASE I € <br /> APPLICATION ACCEP DATE y- <br />`' ADDITIONAL COMMENTS: s �= 1` .h i= ,� �, ' <br /> PUALS& I ROUT INSPECTION �NPEI / NL INSPECTION <br /> JK Z-A DATEINSPECTI INSPECTION BY •=DATE. <br /> 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GRO TING AND FINAL INSPECTION. <br /> E x 1426 5/731M <br />