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W � Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave,.', Stockton, Calif. <br /> Telephone (209) 466--6781 <br /> APPLICATION FOR-0WELL,CONSTRUCTION OR PUMP PERMIT. A ,Permit No. f-' <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, ,r"it to construct <br /> and/or install the work herein described-. " - This:application is made in compliance. with San Joaquin <br /> County Ordinance. No. 1862'and the'Riiles �and"Regulations. of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION jS0 Q Me CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> Cityfdu <br /> Contractor's Name / License 4� Phone _ Cf <br /> !aG(v <br /> TYPE OF WORK (Check) : NEW WELL j / DEEPEN "/-7 RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 w <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 REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _. <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 REPORT of the well and notify them before putting the well iuse. The above <br /> /_ <br /> information is true the best of my knowledge d belief. <br /> SIGNED C2 TITLE - <br /> (DRAW PLOT PI RSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE �. -g•'�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY c� DATE _�► ,_� <br /> CALL FOR A GROUT .INSPECTION .PRiOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />