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f <br /> / n ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I OF. OF1"ICE USi' 1601 E. Hazelton Ave., Stockton, Calif. <br /> �^ <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z�J �a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IsisuedL/ ff-Zr <br /> (Complete In Triplicate) } <br /> .Application is hereby mmade to the San Joaquin Local Health District for a permit to construct <br /> aid/or install the work herein described. , This application is made in compliance with San Jbaquifill <br /> County Ordinance No, '1662 and the Rules and Regul tions of the. San Joaquin Local Health District; kb <br /> JOB ADDRESS/LOCATION ��0 / �1 lV f� CENSUS TRACT <br />{ a s Owner's Name f—a r✓ � � Phoneb� <br /> address _J-31� �&• VN <br /> ' Contractor's Name �gE /�x- C>",P� License X-0-37ahone44&7o6� <br /> �4 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN./-7 RECONDITION 1-7K DESeTRUCTIO <br /> w `�} PUMP INSTALLATION . PUMP REPAIR J / P T J? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES PIT PRIVY <br /> SEWAGE DISf 6SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTf.NDr) USE TYPE OF WELL CONSTRUCTION SPECIFICA4IONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ $ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ,X Gravel Pack Depth of Grout Seal <br /> Other _/ Rotary Type of Grout <br /> Other Other Information <br /> PLff' INSTALLATION: Contractor <br /> r 'E _ Type of Pump H.P. I <br /> =. :s PUti,T REPLACEINENT: / State Work Done <br /> f f P43;fP 7.EPAIR: / I State Work Done <br /> r DFsTRUCTION OF +-,ELL: Well Diameter Approxima �e th lel <br /> Describe Materia_j_andLProc r �NCs <br /> TI <br /> r :z Y I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districts <br /> .01t�,�a tom; and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS �n <br /> caf-ter completion of my work on a new well, I will furnish the San Joaquin Local Health District."8 � <br /> liHLL DRILLERS REPORT of the well and.motify them before putting the wall in use. 'The above " t <br /> information is true to the best of my knowledge and belief. <br /> =!t SIGNED TITLE <br /> , i¢ #r DRAW PLOT PLAN ON REVERSE SIDE <br /> L < 'T'= iEtut <br /> iLLx>1 tr FOR DEPARTMENT USE ONLY <br /> ' . <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> y ADDITIONAL COiuu NTS: P <br /> ' PHASE II GROUT INSPECTION PHASE I I FINAL IN5PECT ON <br /> . / ` <br /> INSPECTION BY DATE INSPECTION BY-DATE` JU .' <br /> '-; CALL FOR A GROUT INSPECTION PRION: TO GROUTING AND FINAL INSPECTION. <br /> A <br /> r� zw r. 3! 1426 5I731M <br />