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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOP. OFFICE U53,: Telephone: (209) 466--6781 <br /> .�----- - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �.77 <br /> (Complete In Triplicate) mit to construct <br /> Application is hereby rade to the San Joaquin Local Health District for a per <br /> and/or install the worf herein described. - This application is made in compliance with San Joaquin <br /> Count y Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local: He41th District. <br /> �/ , e� CENSUS TRACT <br /> JOB ADDRESS/LOCATION axe ,� / <br /> M Phone S'l© t �- <br /> owner's Name' <br /> city , <br /> Address, <br /> _ E".' Phone <br /> • d1�- License #&L <br /> Contractor's Name _ �. <br /> TYPE OF <br /> WORK (Check) : NEW 14ELL K DEEPEN -f / <br /> I'�+' RECONDITION. / I DESTRUCTION <br /> � <br /> PUMP INSTALLATION <br /> REPAIR / / PUMP REPLACEMENT <br /> Other YJ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E " , <br /> SEWAGE DISPOSAL FIELD '' G SSPOOL/SEEPAGE PIT ft R Ld <br /> kTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Cable Tool Dia.of Well Excavation <br /> Industrial �- Dia, of Well Casing r� <br /> Domestic/private <br /> rivate Drilled d <br /> --- �' -- Driven Gauge of Casing [t - <br /> Domestic/public,: <br /> iGravel, Pack 1Septhrof Grout Seal, ra <br /> _ Irrigation <br /> Other Rotary:_ �,,. � T_y-,pe_of,�Grout .r <br /> ik Other _ Other Information_ <br /> PUFF INSTALLATION: Contractor ' <br /> H.P. <br /> Type of Pump k. Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR• � � / / State Work Done <br /> ;, APProx�mate-D-pth _ <br /> 1 DFgTRUCTION OF WELL: We I3iameter r, <br /> Describe Material and Procedure <br /> I hereby agree to coup ly with all laws and regulations oftheSan Joaquin Local Health District <br /> a and the State of California pertaining to or regulating wdli"construction. Within FIFTEEN DAYS <br /> E <br /> after completion of .E[iiy work an a new well, I will furnish the San Joaquin Local Health District <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 /> TITLE ' U <br /> P� SIGNED - <br /> :.. . (DRAW PLOT PLAN: <br />