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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O� ... ' E USE, V"�1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7.7 J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued 6 <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 shade in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health Dis 4rict. <br /> JOB ADDRESS/LOCATION � � r+ 4wol, CENSUS TRACT <br /> Owner's Name v - A� ` Phone 9 — a2 <br /> Address City J <br /> Contractor's Name �^ .,� /� License � 0 7 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION f-1 DESTRUCTION J`7 <br /> PUMP INSTALLATION REPAIR /—/ PUMP REPLACEMENT /-7 <br /> OtherWe <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 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. <br /> PUMP REPLACEMENT: ( / State Work Done <br /> PUMP UPAIR: / / State Work Done <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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPO he well and notify them before putting the well in use. The above <br /> znformat' a to the best of my knowledge and belief. <br /> SIGNED TITLE t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY r` DATE (7 - <br /> ADDITIONAL CO:gFENTS: <br /> PHASE 11 GROUT INSPEO0ftON PHASE UVFINAL INSPECTION <br /> INSPECTION BY O TE T/ 7 K INSPECTION BY DATE/ 7- S <br /> CALL FOR A GROUT INSPE ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - K/73im <br />