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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z �J� <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued,:Z_ z,o,_� <br /> f (Complete In Triplicate) <br /> Application is hereby made 'tolthe San- Joaquin Local Health District for a permit to construct <br /> d. This application is made in compliance with. San Joaquin <br /> and/or install the work herein describe <br /> County Ordinance No. 1862 and'-the Rules and Regulations of the San Joaquin Local Health D1strict. gg <br /> 9 <br /> `-:JOB ADDRESS/LOCATION l �'� Lh CENSUS TRACT <br /> Owner's Name 0^ �� W 11,� Phone <br /> /c��'/.� City <br /> Address =���a r �CO-s_s���� <br /> I License 4�11J�Phone <br /> Contractor s Name SS�__ . <br /> �r <br /> TYPE OF WORK (Check) : NEW WELL YDEEPEN/�/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / I PUMP REPAIR '/ I PUMP REPLACEMENT t <br /> Other <br /> DISTANCE TO NEAREST: SEPTICITANK S SEWER LINES PIT PRIVY <br /> FIELD CESSPOOL/SEEPAGE PIT ` <br /> SEWAGE DISPOSAL � OTHER <br /> � r+' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial i Cable Tool Dia. o€ Well Excavation <br /> Domestic/private <br /> Drilled Dia. of Well Casing, <br /> Domestic/public i Driven Gauge of Casing <br /> ,W.. <br /> Irrigation', Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout ` <br /> *.; Other Other Information • <br /> PUMP INSTALLATION: Contractor "k <br /> H.P.- <br /> Type; of Pump", ' : �. <br /> PUMP REPLACEMENT: State Work Done I2 C I <br /> PUMA REPAIR: / / .'State Work Done <br /> ESTRUCTION OF WELD: Well Diameter _49 2� I #� Approximate Depth 1 <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 Focal 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 and belief, <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN-ON REVERSE SIDE -S7_ <br /> FOR DEPARTMENT USE ONLY <br /> 14-2 <br /> I PHASE I DATE ' - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> } PHASE II GROUT INS CTION P SE III FINAL INSPECTION <br /> INSPECTION BY DATE 7 2- INSPECTION BY Y DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> � 4J72 lri <br /> E H 1426 <br />