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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 76T.". I'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby :Wade 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 ��} N�RSLCA r0M174_jZ/VL-;' PCENSUS TRACT - <br /> Owner's p <br /> Owner's Name - - _ Phone 3 .2-Z .?, <br /> AddressCity �C <br /> Contractor's Name L f 1­4IA16 License #/,?4roPhone 746-10S7_2'- <br /> TYPE OF WORK (Check) : NEW WELL / .DEEPEN'/ / RECONDITION / / DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PL'Mp REPAIR /-/,-PUMP REPLACEMENT /7 <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 /> i Industrial. Cable Tool Dia. of Well Excavation <br />}E 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 0ther..Information <br /> E. <br /> PT)ME' INSTALLATION: Contractor • ��• <br /> -7 <br /> �H.P.Type of Pump re <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR. / / state Work Done <br /> DF-,TRUCTION1OF 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 /> 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. <br /> x4 . <br /> SIGNED TLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G <br /> t APPLICATIONCACCEPTED .$Y-" i DATE 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II-GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYE DATE INSPECTION BY DATE /OL -rF e <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 y 5/731M_.._.__..____ - <br />