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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF.:OFFICE USE: 1661 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) "466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 36P41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -issued <br /> (Complete,, In Triplicate) L lj� <br /> Application 'is "hereby-made to the San Joaquin Local Health District for a permit to cony ttuct <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 Sari Joaquin Local Health District.' I <br /> YJOB ADDRESS/LOCATION ENSUS TRACT . <br /> Owner's Name Phone ' tQ} .i <br /> Address L[J City <br /> Contractor's Naive _` '(.lJ x �` �• �� License #/ hone <br /> TYPE OF WORK (Check). NEW WELL' DEEPEN '/ /-RECONDITION,/` / -DESTRUCTION <br /> .` PUMP ,INSTALLATION` /. /w: PUMP REPAIR / / PUMP REPLACEMENT <br /> N Other r - <br /> DISTANCE TO NEAREST: SEPTIC TANK- ., SEWER LINES ,PIT PRIVY d, rt <br /> SEWAGE,D' ISPOSAL FIELD CESSPOOL;/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation _ _�. 0 <br /> . <br /> Domestic/private Drilled Dia. of Well Casing 9 `1- 1, - <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 /> { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUN(P REPLACEMENT: / State Work Done <br /> PUMP 'tEPAIR: /% State Work Done - f.-K <br /> r, <br /> ,DFSTRUCTION OF WELL: Well Diameter � rl Approximate Depth ZZ { <br /> r - Describe Material and Procedure 'L <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 /> 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 /> �". s <br /> SIGNED TITLE r <br /> DRAW PLOT PLAN ON REVERSE SID <br /> ;y, FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE. II14FINAL INSPECTIO ,� <br /> INSPECTION BY DATE INSPECTION BY f DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7 W 1A?A ff /7'1 y z. <br />