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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />rEOR OFFICE USE: / 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7. � 5 y ;- <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /p,2 � <br />(Complete In Triplicate) <br />.pplication 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 Joaqui <br />^ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />'JbB ADDRESS/LOCATION 9n Al CENSUS TRACT : ' 7 <br />aner's Name _ 0 E' Np S�(%Zr�_) Phone ,:3zs O -74r <br />Address ;)-:3 q .o_ �cz// City <br />,lntractor's Name w� a ,% A � License #IVA& Phone <br />—(PE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION / <br />PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br />Other / / <br />Ll\LLl\L8L' van <br />Industrial <br />_ Domestic/private <br />Domestic/public <br />Irrigation <br />Other <br />JMP INSTALLATION: <br />SEPTIC TANK ' - SEWER LINES PIT PRIVY <br />S WAGE DISPOSAL FIEL�D� a CES POOL/SEEPAGE PIT OTHER <br />TYPE OF WEL v CONSTRUCTION SPECIFICATIONS <br />Cable Tool Dia. of Well Excavation <br />Drilled Dia. of Well Casing <br />Driven Gauge of Casing <br />Gravel Pack Depth of Grout Seal <br />Rotary Type of Grout C <br />Other Other Information <br />IN <br />Contractor s' <br />Type of Pump , H. P. 3 <br />JMP REPLACEMENT: / / State Work Done <br />PUMP REPAIR: / / State Work Done <br />iSTRUCTION OF WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />.ad 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 />,LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />formation is true to the b t of my knowledge and belief. <br />�. 1 o i <br />cIGNED <br />TITLE <br />\J FOR DEPARTMENT USE ONLY <br />PHASE I <br />?PLICATION ACCEPTED BY ri''. -.r .t �,.�;"' DATE .147 <br />MODITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />ZSPECTION BY DATE INSPECTION BY / DATE , ' - j? c✓ .•'.S <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 7172 1M <br />