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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ia 0F. OFF ICS; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,.��__ . d <br /> 7Z/- Z/,/"P P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued _ _27 7� <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 61 the Rules nd Re gu ations of the San Joaquin 'Local Iteal,th District. } <br /> JOB ADDRESS/LOCATION !!:7 CENSUS TRACT ' <br /> Owner's Name _ Phone , y �� <br /> Address �; ,._. �C'f,�/Th—C'A' S Cit <br /> Y__ <br /> Contractor's Name License # Phone ' !! <br /> TYPE OF WORK (Check) : NEW WELL /,X DEEPEN 'f / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION % L'MP REPAIR'/ / PUMP REPLACEMENT <br /> # Other <br /> DISTANCE TOr NEARESTSEPTIC TANK ? EWER LI ES �� SIT PRIVY �p <br /> SEWAGE DISPOSAL FIELD f�ESSPOOL/SEEPAGE PIT _,_ O HER <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> � <br /> Industrial ;` Cable Tool Dia. of Well Excavation 7 <br /> ��Jomestic/private Drilled Dia. of Well Casing C���W <br /> Domestic/public Driven Gauge -of Casing <br /> Irrigation ��--Gravel P&ck-- DiFpth-of.=Grou-t- D_L.I�kc dz=Q _ <br /> Other, tai ary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor 1W. �¢— <br /> G 4 Type of Pumpc/ H.P. / — <br /> y t <br /> .'-PUMP REPLACEMENT: / / State Work Done <br /> ,PUMP 'ZEPAIR: _ / / State Work Done,.....--_.,--------_ <br /> , <br /> .DFgTRUCTION 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 "construction. 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 thewell and notify them before putting the well in use. The above <br /> inform on cis true to the be t of o dge and belief. <br /> t1 <br /> SIGNED � a TITLE <br /> -_/ PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> SE I <br /> APP ED .B'Y DATE Z7 t <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUj INSPECTI N PHASE III/ NAL INSPECTI4 <br /> INSPECTION B DATE F 3 INSPECTION BY/,-,- <br /> CALL <br /> Y TE <br /> CALL FOR A GROUT INSPECTION PR -0R TO GROUTING AND FINAL INSPECTION. ; <br />