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SAN JOAQUIN LOCAL HEALTH DISTRICT �� y <br /> FOR OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;�g� <br /> THIS PERMIT EXPIRES 1 YEAR T'RO`P DATE ISSUED Date Issued �3 <br /> .(Complete In Triplicate) Lp 3 rt 0 2--2- <br /> Application is hereby mad� 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 .Regulationps of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION�_Z/�, fi d r �� 0/7-A a C NSUS TRACT " <br /> 4 <br /> Owner's Name s 1 Phone ' ' ` <br /> Address City <br /> Contractor's Name License # Phone <br /> - TYPE OF--WORK(Check) : NEW..WELL /-/ -DEEPEN"^/-I - RECONDITION"/7-DESTRUCTION'/ <br /> PUMP INSTAi.LATION PUMP REPAIR / /�. UIP REP EMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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' I ~� G <br /> Domestic/private Drilled Dia. of Well Casing + <br /> Domestic/public Driven Gauge of Casing + �? <br /> Irrigation Gravel Pack Depth of Grout Seal _ 1 <br /> I' Other Rotary Type of Grout <br /> k Other Other Information <br /> r t ` <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. /00 <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP REPAIR: / / State Work Done <br /> �'. <br /> ,DESTRUCTION OF WELL: Well Diameter � � - ApProimate 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 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 be of my knowledge and belief. <br /> SIGNED TITLE` �.G-z- ur <br /> ! (DRAW PLOT PLAN ON REVERSE SIDE <br /> F_QR D MENT USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEPTE Y DATE _ �� ' 3 <br /> ADDITIONAL COMMENTS:: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / Z1 =2�r7y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 1M . <br />