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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOf, OF ICE USE: X1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ ,..�.� 1 Telephone.: (209) 466-67$1 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pernit No. 7SL-S S7G� <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. �lieal.i.h District. <br /> JOB ADDRESS/LOCATION / / /`�i CENSUS TRACT <br /> Owner's Name <br /> /l /!/ /li _ Phone <br /> i � G� C �ai/� ., .._... <br /> Address City.��'� I <br /> Contractor's Name �' ��.� License # one i <br /> TYPE OF WORK (Check) : EW WELL /�/ DEEPEN -/:j RECONDITION [—/ DESTRUCTION /- i <br /> UMP •INSTALLATION { / PUMP REPAIR L/ PUMP REPLACEMENT /7 <br /> ( therl./ <br /> DISTANCE TO NEAREST: S PTiC1TA.vK SEWER• LINSS PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELD 14 CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool: Dia`:�of Well txcavati.on' <br /> Domestic/private it Drilled _ Dia, of Well basing <br /> Domestic/public I Driven Gauge of Casing <br /> -- — - - -- - _�' <br /> �_______ t g & - <br /> Irrigation ':1 Gravel Pack Depth of GroA Seal <br /> Other a Rotary Type of Grout <br /> i t Other Other Informal ion F <br /> 11 T <br /> P'00 INSTALLATION: knt :acto <br /> ype f Pump <br /> H.P. <br /> _.._. _..._- <br /> PUMP REPLACEMENT: / IStati Work Done <br /> PUMP 'tEPAIR: { !State' Work Done <br /> hr <br /> DFRTRUCTION OF WELL: elI Diame er /App xicnate Depth/�' <br /> 'Z X) <br /> ese ibe Materialand Procedure <br /> S'ti� ; <br /> I hereby agree to comply ith al Laws aAd regulation of he ah�:Joaq 1 'Focal e thl stric <br /> and the.S.tate a_geri .g_t11 onr_rear+Tatig-tr � cortci on. -Within FIFTEEN DAYS <br /> after completion of my work on 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 /> information is true to the best of my knowledge amci--bel.ief:'r <br /> SIGNED <br /> TITLE r <br /> F1 (21TA;j PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY E <br /> P iA S E I � <br /> APPLICATION ACCEPTED BY f DAT C:IM, <br /> _ 1 <br /> ADDITIONAL, CO.%LM-NTS: <br /> PHASE II I E Oar PHASE III'/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A G OUT IN ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> _E 11 1426 WNIM <br />