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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> ior..'OFF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. V 9.S k) <br /> 7w ,TT yoa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED. Bate Issoed �2. 27-_Tri <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, <br /> s ZL �'� CENSUS 'TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name �- <br /> Address C'[ �- 1` l Lr� rC� City <br /> Contractor's Name License � S Phane S&0 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \ <br /> Domestic/public Driven Gauge of Casing �- Q <br /> Irrigation Gravel Pack Depth of Grout Seal �Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Lam'-�'� . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wark Done <br /> PUMP 'tEPAIR: / / State'Work Done <br /> f DFgTRUCTION OF WELL: Well. Diameter >-._ _ " f' Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply. with all laws`andfregulations 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, rl 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 /> i nfar n i7,s t e to the best of my knowledge and belief. <br />! (y <br /> SIGNED �_ TITLE <br /> s <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> { FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE .� <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> �/731M �y, <br />