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4ZZ-_-)1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. <br /> FFICE <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67E1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No•J ��"jl <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued Za��2 � <br /> (Complete In Triplicate) i <br /> lication is hereby made to#the San Joaquin Local Health District for a permit to construct <br /> ApP , This application is made in compliance with San Joaquin , <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and' the Rules and Regulations of the San Joaquin Local Health Bis riot. r <br /> CENSUS TRACT � <br /> JOB ADDRESS/LOCATION p <br /> Phoned ,V <br /> Owner's Name <br /> Address <br /> IfC <br /> License �� Phone 1111o. t -� <br /> Contractor's Name - _ J <br /> . I I EPEN / I RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> TYPE OF WORK (Check): NEW WELL DE <br /> I? <br /> PUMP INSTALLATION /i;;"Pi,'MP REPAIR// / PUMP REPLACEMENT <br /> Other. / / <br /> .1 PIT PRIVY <br /> DISTANCE TO NEAREST: SEWAGE i DISPOSAL FIELD SEWER LINECESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> _ yZ <br /> t Industrial _ Cable Tool" Dia. of Well Excavation ? <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> ! <br /> Driven Gauge of Casing <br /> Domestic/public <br /> ^� Irrigation "i Gravel Pack Depth of Grout Seal <br /> -Other 1 Rotary Type of Grout <br /> j Other Other Information ' <br /> PUMP INSTALLATION: Contractor H.P. _ w <br /> Type .of Pump ��N1 <br /> PUMP REPLACEMENT: / j ; State Work Done <br /> + I'UNP_'tEPAxR:. _ _ _ //.. .S.tateYWorkOon.e.— <br /> k1.. <br /> `• Approximate Depth' <br /> DFTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> "4 <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 an 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 /> TITLE <br /> SIGNED <br /> 110"{DRAW PLOT PLAN ON REVERSE S ) <br /> x FOR DEPARTMENT USE ONLY <br /> PHASE I a , I Q DATE <br /> APPLICATION ACCEPTED .BY`� <br /> ADDITIONAL COMMENTS: p I /FINAL INSPECTI N <br /> PRASE II GROUT INSPECTION INSPECTION BY DATE ' <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON• <br /> 5/731k <br /> a. 11-1 — <br />