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/ w a <br /> V <br /> SAN- JOAQUIN LOCAL HEALTA DISTRICT _ p <br /> FOF,,OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. e " Dull <br /> Telephone: (209) 466-6781 <br /> jr .dpi APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS-SiS4/ <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued �r.- <br /> (Complete In Triplicate) Q' <br /> Application is herebyde to the San Joaquin Local Health District for a permit to construct 'd <br /> and/or install the wor, herein described. , This application is made in compliance with San Joaquin <br /> County Ordinance No. 1�/�+6,2 and the Rules and Regulations of the San Joaquin Local Health Districth <br /> JOB ADDRESS/LOCATION . 00-6 1A) ,: e �;� �� Q _ CENSUS TRACT <br /> Owner's Name O. ,2 {C40 Phone Q/L - 777 1o02-�r <br /> Address City <br /> a <br /> Contractor's-Name �ig�pf[ , ,r,_�s License U Phone IVCC-40696 <br /> TYPE OF WORK (Check):. NEW WELLg/T DEEPEN /% RECONDITION /7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION X1 PUMP REPAIR'/ / PUMP REPLACEMENT J=7' <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK 17 ir <br /> SEWER LINES PIT SEWAGE DISPOSAL DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �' Cable Tool Dia. of Well Excavation s <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .. CgA -j&a P U , u <br /> 41 Irrigation Gravel Pack Depth of Grout S a1 <br /> Other <br /> _� Rotary Type of Grout � T <br /> A Other Other Information �' <br /> n <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP 'tEPAIR: / 7 State Work Done <br /> i ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> l <br /> I hereby agree to c ly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Caii1fornia pertaining to or regulating well construction. Within FIFTEEN DAYS, <br /> after completion of may work on a new well, I will furnish the San Joaquin Local Health District:;a <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> j information is true to the best of my knowledge and belief. <br /> t <br /> SIGNED ' TITLE 'tls ` <br /> i <br /> &' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / i <br /> J 1 PLICATION ACCEPTED Y `_- U /� DATA- <br /> ADDITIONAL COMMENTS: l <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY d DATE INSPECTION BY I -j _YL DATE -Lz,7 - (� <br /> CALL FOR A GROUT INSPECTION PRIOR-.TO GROUTING AND ,FINAL INSPECTION. v <br /> E H 1426 `$/731M E'� <br />