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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FD£ OFFIL'E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -" Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S Y3 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> F (Complete In Triplicate) L qe-lev---C7t? <br /> Application is hereby rude 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 Sat Joaquin <br /> County Ordinance .No. 1862 and stheiRules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` I A Z. v .Gl CENSUS TRACT <br /> Owner's Name " , X Phone <br /> Address G i� City <br /> Contractor's Name J ; <br /> License l�'�z-jiY, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/47 DEEPEN '/— RECONDITION DESTRUCTION DESTRUCTION /,,7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAI'.4K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 1` Gravel Pack Depth of Grout Seal <br /> Other iRotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter `' Approximate Depth <br /> Describe Mate iar and ProcedureWZ711 I A,4. <br /> �- <br /> Ic <br /> �� f <br /> I hereby agree to comply with all 1 s and regulations of the Sa 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 well1. <br /> 'and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ,,. X, �'!/A[+� I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP ION P S I /FINAL IN5PEC I <br /> INSPECTION BY M ja DATE' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> __ , 1 5/731M <br />