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S C6 / SAN JOAQUIN LOCAL HEALTH DISTRICT T <br /> FOR"OFFICE USE: ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-x6781 <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 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 Joaqt <br /> County Ordinance No: 1862 andGithe Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION' A .gmpo co /»r+✓-AJ 20 ,vaR->s/ 0-) �i 9Nd <br /> �o s i 4 �' o �' �+a 17 CENSUS TRACT <br /> Owner's Name Iyl"� ,�ti,1J Phone <br /> Address 21379 N, city �gerlm�o <br /> Contractor's Name Son Joaquin Pump Co. License 11 /6-37Y Phone r` <br /> msion o an 10oya <br /> c. <br /> Lod' Caiifamia 9520 <br /> TYPE OF WORK (Check) . EW WELL / / DEEPEN /_% RECONDITION "/ - DESTRUCTION /—] <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /2, 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 5 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 5 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven j 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. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> �7 t <br /> PUMP REPAIR: ///State Work Done <br /> i <br /> ESTRUCTION OF WELL: WeIVDiameter Approximate pproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withnall 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 i <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 /> SIGNED 1 TITLE San Joaquin Pump Co. <br /> an Joa uin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE 7�I N Sacramento St. <br /> FOR DEPARTMENT USE ONLY Lcdi, Ca!ifornio S <br /> PHASE I <br /> APPLICATION ACCEPTED BY A/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY G' DATE - ' -( <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> n » •ins .. .__ _ <br />