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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. + <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 s}o <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued CA_,z _,73 <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 klealth District, # <br /> JOB ADDRESS/LOCATION /44- /440 2r0.C� & -44 ! o.. . CENSUS TRACT <br /> f i <br /> Owner's Name ___. /erj _ Phone <br /> Address �City . . � <br /> Contractor's Nage <br /> l License # 11 I-J'Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT L� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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. /IL --- <br /> PUMP REPLACEMENT: / State Work Done 14A n "L //J- <br /> PUMP <br /> /PUMP 'tEPAIR: / / State Work Done <br /> )FgTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> fi <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 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 in use. The above <br /> information is true to the best of my know e e a d belief. <br /> tE <br /> 1 . <br />] SIGNED ITLE <br /> ? <br /> (DjrAW PLOT 155WNTN JERSE SIDE) <br /> s FOR �TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED . DATE O �3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE` III/ INAL INSP TION <br /> INSPECTION BY DATE INSPECTION BY DAT <br />' `. --. CALL FOR A,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. WA ' <br /> _ _ <br /> /7A 1 m <br />