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IT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£.6F ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. r <br /> Telephone: (209) 466--6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <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 Diarist. <br /> ^j� J <br /> .TOB ADDRESS/LOCATION r���%'�iLlv}� � _ _�/G�s`a�Y��/d`�' CENSUS TRACT � "� V/ <br /> i <br /> Owner's Name Phone <br /> Address City , <br /> License fi Phone d711-310 <br /> 6 <br /> Contractor's Name /il/ i��/c/id � �f �i �. . <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN '/ / RECONDITION I DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /� <br /> Other / / /9 j! <br /> DISTANCE TO NEAREST: - SEPTIC TAi.1K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r OTHER <br /> -p-' _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTIO SPECIFICATIONS <br /> Industrial. Cable Tool Dia, of Well Excavation <br /> 22 <br /> Domestic./private — Drilled Dia. of Well Casing lf1�%— <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other,,,c�X;�/; J e Rotary Type of Grout <br /> Other Other Information <br /> ( ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done �1� 1`.1 � -T}f <br /> PUMP 'tEPAIR: / I State Work Done <br /> ,.))FI-TRUCTION 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 /> after completion of my work on a 4ew well, I will _furnish the San Joaquin Local Health District a <br /> b <br /> WELL DRILLERS REPORT of the well and notify them efore putting the well in use. The above <br /> information is rue to th best of my knowledge and belief. AOV W lz <br /> SIGNED TITLE f2 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Er-+ Q DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II G OUT INSPECTION P E II/F PECTION <br /> INSPECTION BY DATE INSPEIOi , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731-m <br />