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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T. <br /> O1ICL USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> r. 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 7fj� p_,77 <br /> t (Complete in Triplicate) <br /> Application is hereby rude to the San Joaquin Local Health District for .a permit to construct i <br /> and/or install, the work herein described. ' This application is made in compliance with San Joa <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District-. <br /> JOB ADDRESS/LOCATION _I Y U �{ t : <br /> 99 CENSUS TRACT ;Y <br /> Owner's Name <br /> phone 3(�O" `7 <br /> Address <br /> r City <br /> xxik r <br /> Contractor's Name License #0/3,2 none 7 , <br /> r <br /> TYPE OF WORK (Check) : NEW WELL ��PUMP <br /> REGONDITIDN / / DESTRUCTION FTPUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /__7 <br /> DISTANCE TO NEA ST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED US TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilledo' <br /> Dia. of Well Casing <br /> __Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout ea <br /> Other e�Rotary Type of Grout <br /> Otherper--- <br /> Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. k� <br /> PUMP REPLACEMENT f <br /> / / State Work Done <br /> PUMP UPAIR: <br /> / / State Work Done <br /> ,DFsTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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. j <br /> SIGNED <br /> f ` TITLE <br /> (DRAW PLOT PL ON RE E SIDE) <br /> PdASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �/ n <br /> ADDITIONAL COUNTS: DATE Z % ,/ <br /> PHASE II GROUT INSPEC I N PHASE III/FINAL INSPECTION <br /> INSPECTION BY —C { DATE 2-jZ7INSPECTION BY <br /> DATE i1/ 22 <br /> ,yC�eA7L�L1 <br /> FORA GROUT INSPECTION <br /> ; : AIOR TO GROUTING AND-FINAL INSPECTION. <br />