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E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> FOL;0rFT USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ 1. Telephone: (209) 466-6781 <br /> E� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _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;lherein described. ' This application is made in compliance with San Jaaquin <br /> Coast Ordinancce..._No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONl ,�/�J �/ _ „ _ CENSUS TRACT <br /> j� <br /> Owner Ed's Name = -1-y]— _�. ._ 12r?a �C2 r' t 0 Phone R.3 g- 02 R 4 a <br /> Address S va nJCity ZbE <br /> E License �aE 2 7 pJ,�hone <br /> I ��jL <br /> Contractor's Name 'T, �,S �n�rJ ���� - �� <br /> .I <br /> TYPE EOF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION,RECONDITION /y:/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PLW REPAIR PUMP PREPLACEMENT /� <br /> Q ther / ,z <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 /> i� Domestic/private Vii- } ,bribed Dia. of Well Casing <br /> i� Domestic/public-e y } + Driven Gauge of Casing <br /> EI Irrigation `r } Gravel Pack Depth' of Grout- Seal <br /> ii Other ��4 - to -Rotary• �' Type of Grout <br /> Other z Other Information ' <br /> i <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump <br /> PUMP PREPLACEMENT: / / State Work Done ! <br /> .:., u •r-+- - Y nom. ; �ja.�i!G,• } <br /> PUMP 1'tEPAIR*' JS tate Work.Done <br /> ,DF1,TRUCTION OF WELL: Well Diameter '+ Approximate Depth <br /> "Describe Material and Procedure <br /> I <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 /> WELL1IDRILLERS 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 /> SIGNED TITLE <br /> IN (DRAW PLOT PLAN ON REVERSE SIDEr4eL <br /> . 4 <br /> FOS DEPARTMENT- USE ONLY F <br /> PHASE I _ - - <br /> APPLICATION ACCEPTED BY DATE ? + <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROAT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY t DATE _Y/ 9 7[! <br /> —•CALL- FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E11H 1426 5/7311 1 <br />