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1 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.­,',_�L(o� <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 application is made in compliance'with San Joaquin! <br /> County Ordinance No. 1862 'aiid the Rules and Regulations of the San Joaquin Local Health District. <br /> 11 JOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name Phone <br /> F <br /> Address City <br /> Contractor's Name " �7... �J TT License Phone & >Z <br /> TYPE OF WORK (Check): NEW WELL' / DEEPEN RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION `/ / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other-/. / <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t 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/private Drilled Dia. of Well Casing <br /> 4 Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Y. Type of'Grout V1 j <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump � , _ H.P. <br /> - orf A <br /> PUMP REPLACEMENT: /V State Work Done <br /> rLUMP`"REPAZR� "'"�"' �` <br /> / / Stade Work Done <br /> J)ESTRUCTION 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`bf California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 41 ter 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 /> SIGNED TITLE Ogg, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F D ARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION P I / INAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTIO BY,_Wft DATE - <br /> F CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />