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I�O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O:F_�01 FINE USL': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 V <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TRIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> I (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 applic4tion 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 />! JOB ADDRESS/LOCATION 'Z � ®� /� /Ii1'd-- d CENSUS TRACT - <br /> Owner's <br /> TRACT -Owner's Name JJ P_r) Phone <br /> I <br /> Address ZZ 3 Al city ' Adi4L-q-FEC f7 <br /> f <br /> Contractor's Name 2SEQUIE <br /> L License �62/OS -Phone SZ 2 S <br /> _ E V FS Q <br /> I TY-PE--UF-WORK (Ghe,ek-): .•NEW--WELL---•.DFrPEN..:./_ / RECONDITION.,/, / -DESTRUCTION /_7 <br />'E PUMP INSTALLATION / / PL"MP REPAIR / / PUMP REPLACEMENT / } <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPT;� TANK A6 NF SEWER LINES /A(j9jV�E_PIT PRIVY /�/_Q/Vj <br /> SEWAGE DISPOSAL FIELD /U CESSPOOL/SEEPAGE PIT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. I <br /> Industrial Cable Tool % Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing %a <br />? Domestic/public Driven } Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �Q _ <br /> Other X Rotary ! Type of Grout <br /> Other Other Information f}IJ <br /> i L <br /> PUMP INSTALLATION: Contractor04 WE, <br /> ` <br /> Type'of PumpH.P.� /40 -° <br /> t PUMP REPLACEMENT: / / State Work Done <br /> =PUMPEPA1--Rr:;:.... /�,/ t t-e--Wo-rk-Done- wil- <br /> A, <br /> pFq RUCTION OFLRLL: WelliDiameter ,..� Approximate Depth.. <br /> -Describe Material and Procedure" -� <br /> i <br /> I Hereby agree tV, omp9y--with all-laws-and regui&tions._.of„-the..San.Joaquin Local,Health District <br /> and the State of California}pertaining to or regud.ating 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 REPORT of the well and notify them before putting the well in use. The above i <br /> information is true to the est o my know dge and belief. I <br /> c <br /> SIGNED TITLE <br /> -*- w- -- - (DRAW, PLO.T_P.LAN ON_REVERSE,S.IDE)..---�__. <br /> FOP,wDEP MENT_1U8&-_0NLYa, <br /> s PHASE I <br /> APPLICATION ACCEPTE DATE ' 3 _ <br /> ADDITIONAL COMMENTS: <br /> I <br /> PRASE II�GROUfi INSPEC ION P SE I / NAL INSPECTION ; <br /> INSPECTION BY 1P_1DATE /- 3� *jZ INSPECT DATE -Z5 7 <br /> CALL -FOR A -GROUT INSPECTION- PRIOR TO.-GROUTING AND FINAL -INSPECTION. 1 <br /> E H 1426 C�17Z,u <br />