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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -4 -3-z 3 <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 Il.eal-th District. <br /> JOB ADDRESS/LOCATION IQ p L�c] �` CENSUS TRACT - <br /> Owner's <br /> RACT -Owner's Named Phone <br /> Address cJ City <br /> Contractor's Name - License Phone 3?28,a�- 2 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION <br /> PUMP.INSTALLATION /_/ PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTICyT&NK SEWER LINES} PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too! Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> Other Rotary -_ Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: � Contractor <br /> Type of Pump H.P. t <br /> I <br /> PUS ' REPLACEMENT: State Work Done <br /> P J76 <br /> PUMP -ZEPAIR, State Work Done , <br /> y <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 I <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 .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 />'F SIGNED 4 TITLE <br />{ (DRAW PLOT PLAN ON REVERSE SIDE?6 <br /> PHASE z <br /> FOR TMENT USE O LY <br /> APPLICATIONACCEPTED . T-6 DATE / 30 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I1111,tANAL INSPECTION <br /> INSPECTION BY DATE INSPECTI0 Y DATE =7 <br /> - CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL .INSPECTION, <br />—_--- E.H 1426 <br />