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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'C}�•:O1'FICE USE 41601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466--6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP .PERMIT Permit No., <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> C #I. (Complete In Triplicate,). _ _ <br /> Application is hereby made. to the San Joaquin Local Health, District for a permit � construct on t uct <br /> and/or install the work herein described. . This -application is made in compliance with San Joaquin <br /> I County Ordinance„ I�o. 1,862 and the Rules and Regulations of the San Joaquin Local. Health Disprict. <br /> JOB ADDRESS/Lf CATIpjN "-' � <br /> f I�IIi' e 3 r CENSUS TRACT ' <br /> Owner's Name / y�� I �'; ' ' Phone <br /> Address <br /> City- <br /> M-0 2L �! <br /> f[ _ <br /> Contractor's Name C4 Z <br /> Z x I P. C 03 License # <br /> ..GQ .Phoney d S <br /> TYPE OF WORK (Check) : NEW WELL ./ / DEEPEN /% RECONDITION /77/ DESTRUCTION /_7 <br /> PUMP INSTALLATION <br /> 0ther1 / / / PUMP REPAIR '/ / PUMP REPLACEMENT 1_7 <br /> a � <br />'¢ DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER—LI ;S _ PIT PRIVY <br /> x <br /> SEWAGE,DISPOSAL FIELD'—,,- CESSPOOL/SEEPAGE PIT _ OTHER <br /> INTENDED USE, ' ' ,TYPE_OF.WELL CONSTRUCTION SP'ECIFICAT'IONS <br /> _ Industrial :� !'-` — . <br /> Cable Tool Dia. of. Well. Excavation ' <br /> Domestic/p-rivate Drilled Dia. of Well Casing T <br /> Domestic/public Driven Gauge of Casing <br /> Ir,riga=ion' -'- _ Gr^avel Pack _ f"'"De_pth of,.Grout_.::Sea1 <br /> Other ` Rotary, -f Grout yFe , <br /> a �f <br /> Other _ Other Information `�`�i <br /> PUMPINSTALLATION; Contr actor <br /> - Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT:} / / State Work Done <br /> PUMP' T�XPAIR: 4 <br /> ! 1--�-S tate Work�Done � <br /> ,DF'sTRUCTION OF WELL: Well Diameter <br /> -- ;r Approximate Depth <br /> w Describe Material and Prescodure -� <br /> I hereby agree to comply with all laws and regulations -of ,the Sart Joaquin Local health District <br /> and 'the State of 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 /> informatio 's true, to the :best of my knowledge and belief. `. <br /> «- <br /> SIGNED <br /> TITLE <br /> (DRAW,TLOT PLAN ON REVERSE SIDE)- <br /> PHASE I .�” � r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL, COMMENTS: DATE 72 <br /> 1 <br /> PHASE II GROUT INSPECTION FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY PHASE IITI DATE Z <br /> 1 <br /> -CALL FOP, A GROUtINSPECTTON PRIOR TO GROUTING AND FINAL INSPEGTTON. <br /> E H 1426 _ <br />