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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FGf. O.1: SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3 L/9� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e <br /> (Complete In Triplicate) �3�-� 1 <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 District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 7T Phone <br /> f <br /> Address City ' <br /> License 4 � Phone ; <br /> Contractor'.-s Name.. _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ j RECONDITION /_/ DESTRUCTION <br /> PULP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 S <br /> Other ./ <br /> R 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> A: Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing` <br /> ; Domestic/public Driven Gauge of Casing <br /> y , Irrigation �� Gravel Pack Depth of Grout Seal <br /> T Other I� Rotary Type of Grout <br /> lit t <br /> Other Other Information - wee <br /> iTr <br /> 4 PUMPS INSTALI.ATION:-- Contractor <br /> Type of Pump Y H.P. <br /> PUMP''REPLACEMENT: / / State Work Done <br /> PUMP '?EPAIR: A j State Work Dome <br /> pFRTRUCTION 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 /> t and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> E after completion of my work on a new well, I will _fiirni.sh 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 /> SIGNED TITLE <br /> (D PL AN ON REVERSE SIDE) <br /> MENT iiSE ONLY <br /> �s APPLICATION ACCEPT BY DATE <br /> ADDITIONAL COMMENTS: °.y <br /> .4 PHASE 11 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Ae - DATE /G-2 y -.7 <br /> - CALL FOR--A GROUT INSPECTION PRIOR-TO GROUTING AND`FINAL INSPECTION. <br /> 5/731M <br />