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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _70—L Oi-i_1C E USIA: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . -,�A�_ <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 District. F <br /> �,Qq �f i. <br /> JOB ADDRESS/LOCATION J- - �j�,C.� � / !_U3 /UP_WC Mj_,tjiSUS TRACT <br /> Owner's Name �,. G„ rj ,CL TCS Phone '163 <br /> Address 3 City -S7z)CK1y_)n1 I <br /> Contractor's Dame (� <br /> l N E, E' 44�'1 PS License 4i`�,_ Phone <br /> - _fie 5e 2�/.� ,.,...,_ <br /> w <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /!./� PLW REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /_7 <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor /t ory ae" -z'Si8 e vice- PGl.mP,5 <br /> Type of Pump TLL2_#gIN:C... , H.P. DC7 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done ` <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure , <br /> r <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 completions 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. <br /> SIGNED Pt4tTITLE &r-'V <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C, DATE <br /> ADDITIONAL =M—NTS <br /> PHASE II GROUT INSPECTION S I I F INSPECTION <br /> INSPECTION BY DATE INSPECTION Y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. //.�3 <br /> EH 1425 51M� ��� <br />