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o-. T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICE- USE: Z1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-11.7�"� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations Qof the San Joaquin Local. Health District. <br /> I Yet <br /> JOB ADDRESS/LOCATION ' ., / 7� ��W✓,fi d1'a CENSUS TRACT <br /> Owner's Name Ci Out, Phone <br /> Address _ �'7 Y' ; �? Y�.�►a cm� <br /> _ City ' <br /> Contractor's Name µ, License #/Jk7k Yhone Y <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/ / RECONDITION-/ / DESTRUCTION TT <br /> 4 PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT II <br /> re Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> © J Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Typet of Pump H.P. / <br /> ? PUMP REPLA'CENIENT: �ff/; State Work Done A, Q <br /> r <br /> PUMP UPAIk: /—T State Work Done <br /> DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <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 'constructi.on. Within FIFTEEN DAYS <br /> after completion of my 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 /> finformation is true .to the best of my wled e a elief. <br /> SIGNED <br /> V <br /> TLE ' <br /> (D W L AN ON RE OKSE SID - <br /> R DEPARTMENT USE ONLY <br /> E: �H.gSE I <br /> .PPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COINR'ENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE +' <br /> 'CAL-L FOR-A.GROM -INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />