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j SAN IOAQUIN LOCAL HEALTH DISTRICT' F� <br /> A <br /> .'OF Oj f iL'E G'S;;; 1601 E. Hazelton Ave., Stockton, Calif. / <br /> - -. <br /> Telephone: 2 (( O 3•+-��w', <br /> r„ P (_09} 466-6781 \ f py <br /> ,-I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe 2 a �(! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -%0-75: <br /> °? (Complete In Triplicate) <br /> application is hereby made to the San Joaquin L4)cal health District for a permit to construct' <br /> and/or install. the work herein described. ' This application is made in compliance with San.Joaquin <br /> 3` County ordinance No. IE62 and the Rules and Regulations of the San Joaquin Local Health 3Districtej— <br /> E FJ "4 <br /> v, JOB ADDRESS/L'6CATIO. d n 4/v/ 6//V <br /> / *" <br /> l C/� l N.� GAJ cExsys TRACT <br /> Owner's Name d ! /27�i Phone <br /> Address <br /> ty <br /> t <br /> Contractor's ;lame ���-�'�} �,,i �� _ I.icense'P-1'313 Phone�v <br /> �.w 4 J <br /> .i3 <br /> a TYPE OF WORK (Check): NEN WELL / DEEPEN /-7 RECONDITION <br /> /7 DESTRUCTION <br /> PUMP INSTALLATION /% PUMP PAIR /% PUPPP REPLACEMENT V ' <br /> N Other <br /> DIST)LtiCE TO NEAREST: SEPTIC TA.;K EWER LINES PIT PRIVY' r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P)xi OTHER <br /> IN17ENDEU USE TYPE OF WELL IO <br /> CONSTRUCTION 5PECIFIGATIIS <br /> = {t> Ir}clustzial Cable Tool Dia. of Well' Excavation 147 '• <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> _ Domestic/public Driven Gauge of Casing /011d <br /> :� 'y:a ._., Irrigation Gravel Pack Depth of Grout Seal <br /> ' a Other —� Rotary Type of Grout <br /> { Other Other Information <br /> '. �N ` <br /> ar PU�a' INSTALLATION: Contractor � <br /> ga Type of Pump H.P. <br /> '+y F ;;� PUY REPLACEMENT: X1 State Work Done <br /> r PUMP UPAIR: / / State Work Done <br /> + ,S DF-CTRUCTION OF WELL: Well DiameterU Approximate _Depth , <br /> is Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Val <br /> pr 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 willfurnish the San Joaquin Local Health District.& <br /> WF,LL.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 TITLE �IW RAJ <br /> ',' ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> Pli,ASE I <br /> e Mr+ w <br /> APPLICATION ACCEPTED BY ;1W <br /> - � DATE <br /> ADDITIONAL CO��\TS: z <br /> ` r PRASE .11 GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY <br /> ' DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 Kl7�lli <br /> = <br /> F • <br />