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y� 9LSAN JOAQUIN LOCAL HEALTH DISTRICT l� !• <br /> Oi. O '1IG: USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13c, s <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE. ISSUED Date Issued K-30 <br /> (Complete In Triplicate) <br /> Application is hereby made toithe San Joaquin Local Health District for a permit to construct <br /> and/or install the wont herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and liegulations of the San Joaquin Local Health District. <br /> JOB ADDRESS JLOCATION _�:r J G l a Off'�t �. - CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address � �„ ��..� " �`' Y� c2f' Cit <br /> Contractor's Name <br /> `License # j��Phone - �G <br /> TYPE Off' WORK (Check): NEW WELL I l DEEPEN '// z.RECONDITION I / DESTRUCTION /? <br /> PUMP INSTALLATION /—/ —PUMP PUMP REPAIR '/x/ PUMP REPLACEMENT« /� <br /> AL <br /> Other 1/7 <br /> DISTANCE TO NEAREST: SEPTICSTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION -SPECIFICATIONS <br /> industrial ' i Cable Tool Dia. of Well Excavation <br /> Domestic/private .:, t. Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other (.'Ill Rotary Type of .Grout <br /> - i Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> TYpe'of Pump ft H.P. Zo <br /> PUMP. REPLACEMENT: /�/ State Work Done <br /> rr`a + <br /> PUMP tEPAIR:.- - /x/ , State .Work Done- <br /> ter_' , - -- <br /> ,D?-, Approximate TRUCTION OF WELL: WeI3`Diameter � pp Depth <br /> Describe Material and Procedure <br /> I� l with all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply <br /> and •the State of ,California pertaining to or regulating we.11'-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Disift a <br /> WELL DRILLERS REPORT''of' the !well. and notify 'them before putting the well in use. The above <br /> j <br /> information is true. to the best .af.my know e ?—e , d..belief. <br /> SIGNED ;� �11ITLE p <br /> t P TN ON .FRSE SIDE) <br /> MVOR DEPARTMENT USE ONLY <br /> PHASE I p *, <br /> APPLICATION ACCEPTED BY ,p - DATE <br /> ADDITIONAL COMMENTS: - i '� <br /> k PHASE I <br /> �LlECTION PHAS III/FI NSPECTIQ <br /> Z .449 <br /> INSPECTION BY DATE. .: .. INSPECTION BY DATE . S <br /> �.CALLwFOR AAGROU INSPECTION--PRIOR TO GROUTING AND FINAL INSPECT <br /> T <br />