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e yy� SAN JOAQUIlf LOCAL HEALTH DISTRICT <br /> POE;O FI(:E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '17-3 Sr/� <br /> A <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 tocconstrutt <br /> is inJpaq <br /> and/ox instal. the work herein described. ' hisul application <br /> tions Ofthe Sane3aaquinpLocale ealthwithSDistrict an n <br /> CENSUS TRACT ' <br /> County Ordinance No. 1862 and the Rules 8 <br /> PUN <br /> JOB ADDRESS/LADDRESS/LOCATION' 4` k Af <br /> C/ G ��- /ZD G Phone 466 -0P 4/ <br /> Owner's Name a <br /> _ <br /> Address L101( <br /> 1 <br /> eop �� License #2.'yz3o3 Phone t/7 - <br /> yfYs <br /> Contractor's Name r�- <br /> TYPE,OF WORK (Check): NEW WELL X DEEPEN '/ / RECONDITION,/p DESTRUCTION / /� <br /> PUMP INSTALLATIONQ' PUMP / <br /> Other} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> C <br /> SEWAGE';DISPOSAL FIELD <br /> J� ESSPOOLjSEEI'AGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I -Cable Tool Dia. of Well Excavation /6" <br /> Domestic/private <br /> j___7 Drilled Dia. of Well Casing 6 . <br /> Domestic/public Driven Gauge of Casing >� <br /> Irrigation . ' Gravel. Pack Depth of Grout Seal j D <br /> Other K ! Rotary Type of Grout <br /> i Other _ Other Information <br /> PUMP INSTALLATION: Contrdctor-, H.P. 3 <br /> Type` of Pump <br /> i h <br /> PUMP REPLACEMENT: j / tate Work Done <br /> PUMP REPAIR• / / +. State WorkDone <br /> h Approximate Depth <br /> pFgTRUCTION OF WELL: Well"Diameter} <br /> Describe Material and Procedure <br /> 1 ` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> California well, I will,pertaining to or regulating well"constructiori. Within FIFTEEN DAYS <br /> and the State of i <br /> E wanew ll furnish the San Joaquin Local Health District a <br /> after completion Ca if <br /> WELL DRILLERS REPORT of ;the well and notify them before putting the well in use. The above <br /> information is true 'to thej est of my knowledge and belief. <br /> + ` <br /> TLE <br /> SIGNED <br /> SIGNED (DCA PLOT PL ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I JDAT 7 3 <br /> APPLICATION ACCEPTED`.BY' <br /> ADDITIONAL COMMENTS: PHASE IIT/FINAL INSPECTI N <br /> PHASE II GROUT I SPECTION INSPECTION BY DATE a <br /> INSPECTION BY DATE <br /> g CALL FOR GROUT I SP CTION PRIOR TO GROUTING AND FINAL INSPEC1TI N. `1 M1 <br /> 1 �� z /, /. arc 4,e Ro �rotaf.ar�t�'Je�r 5,/,731M <br /> �1 <br /> 0'17 f e 5 �� / -- <br />