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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> F'0r.'OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued., I, <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 Sa'nh-Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District,-: '� <br /> JOB ADDRESSILOCATION low f, ev CENSUS TRACT <br /> Owner's Name # 414 Phone <br /> Address v2Z5, 1 i4/�P�i4M 1�� . . . .;... City ' 'ge'lw <br /> Contractor'_s.-Name,y� .� 1 _f _ j' ` . C-. �Lx ns 12A Z Phone 64 <br /> TYPE OF WORK`,(Check) e NEW WELL J,;��DEEPEN '/ f RECONDITION / / DESTRUCTION <br /> PUMP- INSTALLATION /—/ PUMP REPAIR f / PUMP REPLACEMENT /7 <br /> Others <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, '. , PIT PRIVY w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0 Lr) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �-/Cable Tool Dia. of Well Excavation Ap + <br /> �ornestic/privy e Drilled Dia. of: -Well Casing <br /> Domest3.c/publi� DrivenL_g <br /> Ga�ofCasirig.=Irr gation Gravel PaZI3epth of Grout SeaOther -Rotary �Type�,ofjGroutOthersOther Information <br /> PUMP INSTALLATION: Contractor <br /> T3'Pe of-Pump H.P. <br /> f <br /> PUMP REPLACEMENT: _ `" / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> ,DF'CTRUCTION OF. WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure <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 m/work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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, k <br /> SIGNED TITLE wwz" J�}� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION-ACCEPTED.-BX °��` <br /> _ .� °� -- DATE � l <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONl P S I/FI AL INSPECTION <br /> INSPECTION BY DATE az INSPECTION B DATE dy! <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 5/731M�� <br />