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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Haze.lton''Ave.' Stockton, Calif. <br /> Telephone: (209)44666781 <br /> APPLICATION FOR WELL CONSTRUCTION&OR PUMP PERMIT Permit No. <br /> THIS PERMIT -EXPIRES 'lit YEARdFROM<.DATE=,ISSUED§,'t,ol -­,DAtd'-'Issued 7 7 <br /> (Complae-6 Inf'Tr3plie t 3 c v <br /> Applicat*ott) t--)htrebyimadex:to therSan,_rJbaqu nAoeal H6alth Dirstr ct fbrt3aspermit-',tb, corlstxuct, <br /> and/or install the work herein described. Thisf�;application`>is�madea:in:tcompLiancekwith<<SanK'J-oaquin <br /> CountyagrdinaiieeoNo7g1862maiidKth6r,Ru�:es'aand�-�Regulatitons-16f the,San":3Joagti `;},Local•,Hdalth.;Distr-ict: <br /> J_�;ii3.�.Z'J(� 'f:aft:.iL7 yl?fi. Y3 t!ii ?r'�,-. ...:z2i�(?�,'_f:.:• '-iri�iltY�Se, :i: f1s�.f..va>::. i7.7%;(_7i:Q":.'Si .4tq,7�t'4�.. f ,.;4Sy. Lz. <br /> JOB ADDRESS/LOCATION ,z c;C£NSUS4•TRACTI„ " <br /> �t,y 2n r <br /> Owner! <br /> Address <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL' / f DEEPEN '/—/ ; RECONDITION /7 DESTRUCTION /_7 � <br /> f PUMP"INSTALLATION / PUMP REPAIR '/7/ . PUMP REPLACEMENT /7 <br /> . ... _. : Ether ./ / ...:-. . ... .. ... . .. . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE: DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER �) <br /> INTENDED..USE - <br /> "TYPE- OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial.. ._ .; Cable Tool Dia. of WeZ1 .Excavation <br /> Domestic/private' Drilled Dia. of Well Casing <br /> Domestic/p'ublic Driven Gauge of Casing <br /> Irrigation _Gravel .Pack Depth: af Grout Seal <br /> Other Rotary Type of Grout '' <br /> Other 4 Other' Information ' <br /> PUMP INSTALLATION: Contractor r <br /> Type;of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done 3 <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL:: We11,,Diameter— ""���"'""�� - �- - �;•- �Ippraxmate Depth, _ . J <br /> Describe Material and Procedure w <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 bf: 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 ; <br /> (DRAW PLOT PLAIR ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY } <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f7 y i <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT.:INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROiITING AND FINAL INSPECTIO <br /> 1426 . ... . - - _..... __. ._, .,.__ <br /> 4/72 . 1M . <br /> 1 <br />