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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 510T."OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-26;jSy'w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3�t�-76 <br /> ( L77 4,,e Jmplete In Triplicate) <br /> Application is hereby made to the San oaquin 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. 1662 and the.Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o CENSUS TRACT ' <br /> Owner's Name' Phone <br /> c <br /> Cit <br /> Address y <br /> Contractor's Name pLicense 4t�,,4hone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial "' Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotary k Type of Grout <br /> ::i(Other Other Information <br /> PUNK' 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 /> E <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 REPORT of the well and notify them before putting the well in use. The above <br /> r information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE z 2 <br /> ADDITIONAL COMMENTS: <br /> PRAW II 4ROIUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Z INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING .AND_FINAL INSPECTI. ON. <br /> E H 1426 ��"ff'-� oy � <br /> 31M <br />