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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PT <br /> T. Pig, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ,-If 4� <br /> ' THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued a-�.2-7� <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 %4ith San Joaquin <br /> County Ordinance No, 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i .JOB ADDRESS/LOCATION 4- G / ' CENSUS TRACT , <br /> Owner's Name Phone ' <br /> Address city <br /> a G/r?oly <br /> _ P <br /> Contractor's dame P // � ' U ?/� O, License # 7 Phone AXZ- <br /> k — <br /> TYPE OF 1}ORK (Check) , NEW WELL -/` / DEEPEN RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION J PUMP REPAIR / J PUNfP REPLACEMENT /7 <br /> pr Other <br /> DISTANCE TO NEAREST: SEPTIC T)U4K 7S� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p� <br /> Industrial Cable Tool Dia. of'Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing V <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 <br /> _-- -� Type of Pump } H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T Describe Material and Procedure <br /> rt <br /> f <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_45�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 /> WELL DRILLERS REPORT of .the well and notify them before putting the 'well" inyuse. The above <br /> information is true to the best of my knowledge and belief. <br /> ` eV <br /> SIGNED . � C. TITLE'' <br /> D PLOT PLAN ON REVERSE S. �. <br /> PRASE I <br /> OR DEPARTMENT USE ONLY <br /> 4%APPLICATION ACCEPTED BY - _ _.DATE <br /> ADDITIONAL COIMNTS: - <br /> PRASE II GR I P ION P 5Ep /FIN INSPECTION <br /> INSPECTION BY ATE INSPECTION BY ATE <br /> L• GA,:L-FORA-GROUT-.INSPECTION.-PRIOR TO GROUTING AND FINAL. INSPECTION. . <br /> E H1426 -- r�/71�i .. <br />