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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFT.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-•6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. —kP <br /> THIS PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED Date Issued .�...�f-�� <br /> (Complete In Triplicate) R <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 /> 37i � . 2a." 2 -14r7o - v3 <br /> JOB ADDRESS/LOCATION �, , a` k-y 0A IF ©�70 5/ Aelliel .7wd CENSUS TRACT , <br /> fi� � '- L <br /> Owner's Name � <br /> . � 1 S'- nJ Phone 7 .. <br /> Address `3 7-:5 - CS - City <br /> Contractor's Name —1, �e�y%d/cj �tSQ� _ License 4 ]90!pPhone � v7 <br /> TYPE OF WORK (Check): NEW WELL'/ , DEEPEN /_7 RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / '/ ; PUMP, REPAIR /A./' PUMP REPLACEMENT /L <br /> Other I `l r� �d 47 -Se 1-Sr AZ <br /> DISTANCE TO NEAREST: SEPTIC.,-TANK SEWER.LINES PTT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE y, TYPE OF WELL4- :. CONSTRUCTION SPECIFICATIONS <br /> Industrial `s' , #'R Cable Tool Dia:`k of Well Excavation , <br /> Domestic/private Drilled Dia. -,of Well Casing <br /> ._ `,_ <br /> Domestic/public Driven Gauge of, Casing �• <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary 'Type of Grout <br /> Other Other Information <br /> l <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> Q <br /> PUMP -REPAIR. /y Smtate-work Dame` - 1 •` �+� rs+ - Y-� -� <br /> ,DESTRUCTION OF WELL: -Well Diameter -Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Statemof California pertaining to or regulating 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 <br /> information is true to the best of my knowledge and belief. , <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE.SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> APPLICATION ACCEPTED BY J DATE �/ 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTTON P NAL INSPECTION <br /> INSPECTION BY INSP ION B DATE - <br /> CALL FOR A GROUT INSPECTION, PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 7172 IM <br /> H 1426 <br />