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l,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. kHazelton Ave. , Stockton, Calif. _ k <br /> Telephone: (209) 466-6781 <br /> k; APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES-1-YEAR FROM DATE ISSUED Date Issued <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`.I-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 /> JOB ADDRESS/ TION \ CENSUS TRACT <br /> dz _71 <br /> r IA <br /> Owners Name Phone <br /> Address '� U City <br /> Contractor's Name <br /> `�` Li <br /> 1 !h <br /> ►, TYPE OF WORK (Check) : NEW WELL / EN "/ RECONDITION /7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMA' REPAIR / / PUMP REPLACEMENT /� <br /> ' Other <br /> i DISTANCE TO NEAREST: SEPTIC TANG SEWER LINES PIT PRIVY <br /> ti SEWAGE DISPOSAL FIELD ! CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL i. CONSTRUCTION SPECIFICATIONS <br /> Industrial a Tool h Dia. of Well Excavation , <br /> r <br /> 4 mastic/private Drilled ( Dia. of WellkCasing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 'Gr va 6l-PZ1 ma Depth of Grout Seal <br /> Other + Rotary Type of Grout <br /> k Other t Other Information <br /> _4 <br /> ;w <br /> PUMP INSTALLATION: Contractor' ° ` <br /> Type of Pump .ti H.P. <br /> PUMP REPLACEMENT: State-Wokkn,Done <br /> - -r <br /> 4 PUMP REPAIR:, / / State Work Done_ - - <br /> Approximate A <br /> DESTRUCTION OF WELL: °�' <br /> _ Well Diameter r "`'' pp Depth <br /> ' Describe Material and 'Procedure. <br /> I hereby agree to comply with all lAws and regulations of the Saii 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 /> SWELL DRILLERS REPORT of the well and notify them before puttinkg'Yhe well in use. The above <br /> information is true to the best,o,f my knowledge and belief. <br /> SIGNED 5TITLE -- <br /> .(DRAW PLOT PLAN ON REVERSE DE <br /> E <br /> f FOR DEPARTMENT USE ONLY <br /> iPHASE I DATE <br /> GAPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> w E H 1426 b ' <br />