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FOR OFFI ISE- ✓/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. h <br /> Telephone: (209) 466-6781 'I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR, FROM DATE ISSUED <br /> (Complete In Triplicate) Date',Issued :� 3 <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 Joa u <br /> County Ordinance No: 1862 and the-Rules and Regulations of the San Joaquin LocallIHealth Distric ii <br /> t <br /> JOB ADDRESS/LOCAI� c . <br /> /20W-z CENSUS TRACT <br /> Ownera Name W/(_�P 17-0/A <br /> Address Phone <br /> - - <br /> City <br /> Contractor's Name <br /> i <br /> _ License # Phone <br /> f TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION;/ <br /> _ �T DESTRUCTION <br /> PUMP INSTALLA ON /7' P V� <br /> OtherREPAIR / / PUMP REPLACEMENT ��.<<, �� <br /> DISTANCE TO NEAREST: SEPTIC TAN K <br /> SEWAGE DISPOSAL—FIELD LINES PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT II <br /> �--�- OTHER <br /> INTENDED USE TYPE OF WELL ! <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool Dia. of We11 Excavation <br /> ng <br /> Domestic/public <br /> /private Drilled Dia. of Well Casing <br /> G' <br /> __� Driven . <br /> Irrigation Gauge of Casing .k <br /> Other ---- Gravel Pack Depth of Grout Seal <br /> Rotary T 'k <br /> Type of Grout <br /> Other Other Information <br /> PUMP INSfiALATION: Contractor <br /> Type of Pump k <br /> _ H.P. <br /> PUMP REPLACEMENT: E/ <br /> / State Work Done II <br /> PUMP-REPAIR: . -/--/_r_State Work-:-Done ! a <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Materia] 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 /> Joaquin Local Health <br /> WELL DRILLERS REPORT of the well, and notify them before putting the <br /> after completion of my work on a new well, I will furnish the San well in use. The above <br /> ritt a <br /> information is true to the beat of my knowledge and belief. <br /> SIGNED <br /> TITLE � ' i� <br /> DRAW PLOT LAN 0 REVERSE SIDE �IId <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: D E <br /> PHASE II GROUT INSPECTION .M <br /> INSPECTION BY DATE PHAS N INSPECTION <br /> INSPECTION BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP G `� <br /> E H 1426 } <br /> 7/72 1M <br />