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.l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton Calif. <br /> ___-- —_--- <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit tic,. N o <br /> PERMITTHIPERMIT EXPIRES I YEAR FROM DATE ISSUED Date issued Z,2>�>j <br /> f �{ (Complete In Triplicate) <br /> ZIPPlicani.on is hereby made to the San Joaquin Local Health District for a permit to const!;uct <br /> f <br /> and/or install We work herein described. - This application is made in compliance with Sail JoaguQ <br /> county Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health Disprict. <br /> 0.B ADDRESS/LOCATION d <br /> -- CENSUS TRACT <br /> Owner's Name L 11, <br /> �' '�`� � Phone <br /> Address City <br /> Contractor' ng s Na ;loot;,= F <br /> . RC1 ti .�_� --- License # /,f,,�71,3 Phone <br /> A <br /> TYPE OF WORK (check) : NEW WELL I I DEEPEN/_/ RECONDITION 1-7 DESTRUCTION <br /> PUMP INS'T'ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Cather <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SE[dER LINES PIT PP.IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL � C <br /> CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestic/private Drilled Dia, of Well Casing a <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 /> �PUitt' INSTALLATION: Contractor ;'� .,r'�:r �� � �� <br /> _ _c <br /> Type of Pum _ =° G :, r H.P. 'fes-. �1 <br /> PUMP REPLACEMENT: / q State Work Dome <br /> PUMP REPAIR; / / State Work Done <br /> F.DFATRUCTI.ON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> 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 cor,pletioa of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> FinformaLio <br /> � LL DRILLERS R PORT of the well and notify them before putting the well in use. The above <br /> n is true to the best of my knowledge and belief. <br /> ___.• _ -�� °^"'°�` �°; TITLE <br /> (DRAW 'PLOT" PLAN ON REVERSE SIDE) - <br /> k'Os,R DEPARI'i�NT USE ONLY � <br /> fjASE I ..PLI.CATIOiN ACCEPTED BY DATE <br /> ADDITIONAL COMD&IITS: <br /> PhASE II GROUT INSPECTION, PHAS III:/FI TAL INSPECTI T <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. G <br />