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5Z1601 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />IOF "OE�FICE USE: E. Hazelton Ave.. Stockton, Calif. <br />Telephone: (204) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PEC a it Nod �6 jsti tJ <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -76 <br />fJ 7"K..4Z9_�Plete 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 Jpaquir. <br />County Ordinance No. 1862 and the,Rules and Regulations of the San Joaquin Local health District. <br />e : t • e � � �7�i7��1r! �3r. <br />WPM, ate X"d"moi! A;k <br />Address <br />City <br />Contractor's Name License ��j�hone <br />TYPE OF WORK (Check): NEW 'WELL DEEPEN-! / RECONDITION / / DESTRUCTION f% <br />PUMP INSTALLATION f / PUREPAIR'/ / PUMP REPLACEMENT %% <br />MP <br />. 0 Cher <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL'FIELD CESSPOOL/SEEPAGE PIT OTHER 'S <br />,.p <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br />Industrial r' Cable Tool' <br />Dome stic/privateDrilled <br />Domestic/public Driven <br />Irrigation Gravel Pack <br />Other Rotary <br />Other <br />Dia. of Well Excavation <br />Dia, of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal �1 <br />Type of Grout <br />Other Information <br />PUMP INSTALLATION: Contractor <br />Type of rump H.P. .. <br />PUMP REPLACEMENT: 11 State. Work Done <br />PUMP UPAIR: / / State Work Done <br />,DF",TRUCTION OF WELL: Well Diameter Approximate Dep'tb ' <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 b <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 <br />PgASF I <br />APPLICATION ACCEPTED -BY <br />ADDITIONAL WINMENTS : <br />P F�A <br />INSPECTION BY <br />INSPE <br />DATE <br />TITLE <br />.SE SI <br />ONLY <br />INSPECTION BY <br />DATE 2 <br />AL INSPECTION <br />CALL FOR A GROUT INSPECTION PRION TO -GROUTING -AND -FINAL INSPECTION. <br />E H 1426 �f%lc``aj%�31I <br />