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n f. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> o-FloUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7V- J1q_yO <br /> THIS..PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,2 S zf" <br /> (Complete In Triplicate) <br /> a 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 Joaquii <br /> County Ordinance -No. 1862 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION:! O Al ArA-1-11tCENSUS TRACT <br /> I Owner's Name �� �!O �f •�' _ Phone <br /> Address L� City <br /> Contractor's Name �� *' License 4� / � Phone ,4 <br /> TYPE OF WORK (Check) :. NEW WELL ,/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> I tl <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1 " SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. '6f Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> - - Domestic/public Driven Gauge of Casing <br /> %A Irrigation Gravel Pack • beptV of Grout Seal � <br /> Other • Rotary Typi of Grout .. <br /> a Other 01 ler Information { <br /> PUMP INSTALLATION: Contractor � . <br /> Type of Pump / G' H.P. .p <br /> PUMP REPLACEMENT: State Work Done v- j4w 04r,s <br /> a <br /> PUMP UPAIR: / / State Work Done <br /> DF'zTRUCTION OF WELL:: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> FR . <br /> E 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 Hearth District <br /> WELL DRILLERS REPORT" of the 'well and notify them before putting the well in use. The above <br /> information is true.rto the best of my knowledge and belief.. <br /> SIGNED ITLE <br /> st (D LOT ON R ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I IDATE <br /> APPLICATION ACCEPTED BY . <br /> t 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 SP 0 <br /> 5/731x- <br />