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A <br /> r_ ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOF.rOFFICE USE* 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued .�_/D->3 <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 Jioaquin <br /> County Ordinance No. 1862 _and the Rules and Regulations of the San Joaquin Local- Fieal.th District. <br /> JOB ADDRESS/LOCATION a Gao C YA o Lisa CENSUS TRACT 1 <br /> Owner's Dame tScc7 LA t 411 At Phone ' <br /> Address City0�-E�1`. <br /> Contractor's Name 9-i Aar License �� l Phone �7� � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /- ; <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /- <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 , <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing (•� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout V�1 <br /> Other Other Information <br /> PUMP INSTALLATIONS ,Contractor -� <br /> ,Type of Pump H.P 4CC <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP UPAIR: State Work Done ten <br /> DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> w <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 /> 14ELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to the best of mytknowledge and belief. <br /> SIGNED V V` �i •�`*.. TITLE <br /> � --� ('p "PLOT P AN ON .R ARSE SIDE} <br /> FOR DEPARTMENT USE ONLY y <br /># PHASEI: <br /> APPLICATION <br /> PPLICATION ACCEPTED .B ``����,� DATE <br /> ADDITIONAL COMMENTS <br /> PHASE Il GROUT INSPECTION PHASE III/ INAL INSPECTION 73 <br /> INSPECTION BY DATE- - -- INSPECTION BY DATE f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> q/711 tai <br />