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� P <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PLW. PERMIT Permit No. <br /> T3-,3_17 R <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ;zAlt, 4o a 4 z CENSUS TRACT <br /> v Owner's Name e4- trPhone }3 j [/2 $"C) <br /> Address " j/ City / <br /> Contractor's NameA k License # j 4�Q Phone ? /4pr,Z_ <br /> TYPE OF WORK (Check) : NEW WELL /f DEEPEN /7 RECONDITION /7 DESTRUCTION /r7 j <br /> ' PUMP INSTALLATION / / PUMP REPAIR tPUMP REPLACEMENT /_7 <br /> Other <br /> p <br /> DISTANCE TO NEAREST: SEPTIC TANK /r f SEWER LINES.- -.--PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE '` TYPE.OF WELL 1 CONSTRUCTION SPECIFICATIONS <br /> Industrial "``-`� Cable Tool Dia. of Well Excavation <br /> � ion <br /> Domestic/private Drilled Dia. of Well Casing • •� <br /> Domestic/publ1c, Driven Gaugeeof Casing /¢4A!;k_ <br />� rrigation ».� -,. -ravel Pack Depth ,of Grout Seal o� t <br /> Other f -- — <br /> # Rotary Type of Grout <br /> Other OtherInformation <br /> s <br /> PUMP INSTALLATION-; <br /> ]:z Contractor <br /> Tvpe .,_ Pump H.P. <br /> PUMP REPLACEMENT. 4 / / State Work Done <br /> PUMP REPAIR: Stage Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter App oximate 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 construction. Within FIFTEEN DAYS <br /> after complen of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. <br /> • <br /> iIGNED TITLEly <br /> E <br /> (DMW PLO LAN ON REVERSE SIDE"— <br /> " �. <br /> ~-.—"F R DEPARTMENT USE ONLY <br /> APPLICATION,.ACCEPTED_B _ k.` � - ' + <br /> 4 r rDA =/G� <br /> LDDITIONAL COMMENTS:��1 .3a-3� , <br /> �.,�.m. PHA I I NSPECTI0 <br /> INSPECTION BY OATP, INSPECTION BY DATE <br /> CALL FOR A Y CT ON PRIK110G OUTING AND FINAL IN5 <br /> E H 1426 /72 1M <br />