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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 PUMP PERMIT Permit No. 73 -6 6 CC> <br /> THIS PERMIT EXPIRES :1 YEAR. FROM DATE ISSUED , <br /> i <br /> (Complete In Triplicate) Date Issued <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 /> t JOB ADDRESS/LOCATION <br /> _ CENSUS TRACT <br /> Owner's Name � � Of � <br /> Phone ' <br /> Ph . <br /> _ s! . d�� <br /> Address - r, <br /> �- City <br /> Contractor's Name � <br /> License jj.Zec+79V Phone <br /> TYPE OF WORK (Check) : NEW WELL 'W DEEPEN/? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT/� <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial <br /> Cable Tool Dia, of Well Excalation <br /> Domestic/private Drilled Dia. of Well Cading (� <br /> Domestic ` <br /> _._ /Public Driven Gauge of Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal tJ n <br /> Other Rotary T -• <br /> ype of Grout l <br /> - P <br /> „ �l <br /> Other <br /> Other Information ' <br /> A <br /> PUMP INSTALLATION: Contractor �� �► <br /> Type of Pump h <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: St <br /> ate Work Done , <br /> i <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth . <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 ofmy work on a 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 t e to the best of my knowledge and belief. <br /> SIGNED � TITL � <br /> (DRAW PLO PLAN ON REVERSE SIDE <br /> PHASE I FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 9 i _CL <br /> ADDITIONAL COMMENTS: DATE <br /> PHAS II GROUT INSPECTIO PHAS III FINAL INSPECTIO <br /> INSPECTION BY DATE '7 INSPECTION BY <br /> DATE <br /> CALL FOR A G T INSPECTION PRI R TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 4/72 1M ;'' <br />