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I� SAN JORQUIN ,LOCAL HEALTH DISTRICT ' <br /> FOP. OFFICE USF.: 16dI E. Hazelton-Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�-7� <br /> (Complete In Triplicate) <br /> Application is hereby rade to the San Joaquin Local Health District for a permit to const uct <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 /> 3A4- l uV'Y"5- <br /> JOB <br /> JOB ADDRESSJLOCATION /Q . d S CENSUS TRACT <br /> Owner's Name /..0 ! Qr ! Phone <br /> Address City13 fL?%!CT-OCA_ <br /> -_ ,.F. �. r� r` - #! •��. __ T �: - Phone <br /> t Contractor's Name %� J^Cl�, I �. License # 4 - ? <br /> t <br /> TYPE OF WORK (Check) : ( NEW WELL" ' DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> I PUMP INSTLATION / /f PUMP REPAIR'/ / PUMP REPLACEMENT /LT <br /> AL <br /> Other <br /> DISTANCE"TO NEAREST: ",SEPTIC TANK Z/dSEWER LINES PIT PRIVY &HER1 I'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE .I� TYPE OF WELL - \ <br /> E .Industrial /' Cable Tot Dia. of Well Excavation Y <br /> ,_ Domestic/private Drilled Dia. of Well rCasing y a I .� <br /> ` '"Domestic/public i! Driven �vdG uge of Casing <br /> Irrigation Grave_l�Pack Depth of Grout Seal' i .150 ► __� <br /> Other ,�/ Rotary, Type of Grouti <br /> Other Other Information - <br /> PUMP INSTALLATION: i Contractor <br /> Type of Pump Y ! tot f R.P. i <br /> _.PUMP_REPLACEMENT( .. � ../ ./ State..Wo.r#k;Done <br /> k �� �• ' " ""�" <br /> PUMP REI <br /> AIR: <br /> AIR: I State Work Don <br /> � �� I / <br /> ,DFRTRUCTION OF WELL: Well Diameter .. Approximate Depth <br /> ` Describe Material and Procedure � <br /> l <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 /> Iafter 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 notifythera before putting the well i ruse. The above <br /> information is true :t�ooth`'e best of my knowledge and belief. <br /> SIGNED rt ITLE, <br /> W PLO FLAN ON REV SE SIDE <br /> ' i'. �.' FOR DEPARTMENT'USE ONLY �, { <br /> i <br /> APPLICATIONACCEPTED 11Y.�, � � � �_PHASE � �� VI DATE <br /> ,. ADbITIONAL COMMENTS: 11 ' <br /> PHASE II. . U I CTIO PHAS III/FINAL :INSPECTIObT <br /> ' INSPECTION BY DATE INSPECTION BY _DATE <br /> a CAI.LYYOR A GR UT INSPECTION PRIOR -TO GROUTING AND FINAL INSPECT <br /> II �"'r5/731M- <br />