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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I TOF ,",O-FI ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466--6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7y_ 4�z_r 2e, <br /> k ;THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —.2p_7Z <br /> ., (Complete In Triplicate) <br /> Application is hereby made.1to 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 Joaqui <br /> } ' County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Real.th District. <br /> JOB ADDRESS/LOCATION f6l 1CENSUS TRACT <br /> !' Owner's NamePhone <br /> Address a,2 �i — City 'S Z2C-,& <br /> h <br /> Contractor's Hams _y License # Phone <br /> l TYPE OF WORK (Check) : NEWIWELL f DEEPEN/_/ RECONDITION / / DESTRUCTION /_" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMPIREPLACEMENT' <br /> ;Other `_.._ — i <br /> h <br /> DISTANCE TO NEAREST: SEPTIC TANK ELI SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> • 1 ` <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N4 <br /> Domestic/private Drilled Dia. of Well Casing: <br /> Domestic/public t Driver: Gauge of Casing t F - <br /> Irrigation c Gravel Pack Depth of Grout Seal t 6T <br /> Other Rotary Type of Grout <br /> Other Other Information &L-49ca e l l" -19 <br /> } 1! Q <br /> PUMP INSTALLATION: -Contractor— <br /> .Type,,- of' <br /> ContractorTypi:_of' Pump. H.P. - <br /> PUMP <br /> .P. -PUMP REPLACEMENT: / /' State Work Done <br /> L <br /> f^^^• Y 1. ,;- wrs.ear.o_.1e - • <br /> PUMP 'REPAIR: t/ /64 State .Work-'Done..- _ <br /> DF.gTRUCTION 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 State of California pertaining to or regulating well •construction. Within FIFTEEN DAYS <br /> s 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 tolthe best of my knowledge and belief. } <br /> SIGNEDTITEE <br /> j (DRAW PLOT PLAN ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , ! <br /> APPLICATION ACCEPTED BY -- DATE <br /> ADDITIONAL COMMENTS: t <br /> 1 PHASE II GROUT INSPECTION PHASE, III/FINAL INSPECTION <br /> INSPECTION BY e DATE _a e / . y INSPECTION BY DATE <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS CTION. <br /> x/731"M <br /> E H..1425 g .. <br />