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fL <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT f , <br /> FOr.;O1FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED 7-.3 - � /7 r' <br /> i Date Issued �ZLI 773 <br /> {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 application 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 <br /> tj o CENSUS TRACT <br /> Owner's Name FL VIN Ltl/NCLCL <br /> r Phone <br /> Address 5- M ' 4 <br /> A �7 v A nCity 5'-7&rW <br /> Contractor's Name e v i. <br /> License #.2?Z. o.� Phone <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN/—/ RE NDI DESTRUCTION /-7' PUMP INSTALLATION PL"I�P <br /> /OPUMP REPLACEMEIQT <br /> !/ /- <br /> therq <br /> DISTANCE TO NEAREST: SEPTIC ITANK 00'. SEWERS IVES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C SPOOL/SEEPAGE PTT <br /> _ , ` OTHER _ <br /> INTENDED'USE °moi TYPE OF WE L CONSTRiJCT10 SPECIFICATION$ <br /> Industrial ' <br /> _ Cable T of Dia. of Well Excavation <br /> Domestic/private ria Drille Dia, of Well Casing „ <br /> Domestic/public k Driven Gauge of Casing 7 z <br /> Irrigation Itlt '\G ay- el ack Depth of Grout � • <br /> Other SSeal', '-, otary Type of Grout <br /> 0 her Other Information - <br /> PUMP <br /> nformation -PUMP INSTALLATION: ' Contractor4 z 6 S-7.6 f <br /> pe of Pump <br /> r.-��J f'� <br /> - .... <br /> PUMP REPLACEMENT: / / State WoMrk Done_wan <br /> PUMP UPAIR: V State Work Done T <br /> DFIZTRUCTIRN OF WELL: Well Diameter i <br /> Approximate Depth <br /> .Describe Material and Procedure~._-- <br /> d <br /> I hereby agree toycomply 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 icy work on a new well, I{rill furnish the San Joaquin Local Health District a <br /> WELL DRZLLERSjREPORT of the well and notify them before putting the well in use. The above <br /> information is true (to the best of my knovh6dge and belief. <br /> SIGNED <br /> (DRAW PLOT PL ON REVERSE SIDE) . -- <br /> PHASE I - FOR DEPART [ENT USE 'ONLY >' <br /> .APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: DATE 11z�?7r3 <br /> PHASE IT GROUT INSPECTION F <br /> INSPECTION BYPHASE II/FINAL: INSPECTION <br /> DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E, H 1426 a . <br />