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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;-tit. OF1iCE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 SIfO/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /1 41 -71f- <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 Health District. <br /> JOB ADDRESS/LOCATION tli-nq Tdi o 20111' A/o M'T'h a,Z ex 2-7-6 11 v7r lfd CENSUS TRACT <br /> Owner's name 42A 4 A, -70,a ( Phone 34^ 3G 5!/ <br /> Address :2- 7-v 7 e 72 A City ES e- <br /> �, <br /> Contractor's Name T'a' License # Phone <br /> m�Z � rTC Y �r1c <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION /7,? PULP REPAIR / / PUMP REPLACEMENT <br /> Other / l � 1 Q l' �y?GL.r" ` � G /7` a n�t.zT/ 0.>r <br /> DISTANCE TO NEAREST: SEPTI'C TLik 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 /> tom- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor� � / <br /> Type of Pump1�r_tLc�;z7 G a L �- !L H.P. _! <br /> PUMP REPLACEMENT: State Work Done ,'// / Punnr -Y � <br /> PUMP UPAIR: / / State Work Done <br /> ,DFgTRUCTION 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 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 knowledge and belief. <br /> "' <br /> SIGNED ., TITLE . . <br /> DRAW PLOT PLAN ON REVERSE SIM <br /> FOR DEPARTMENT USE ONLY <br /> P4iASE I <br /> APPLICATION ACCEPTED BY (L ' �] ,��p DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY + = - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />