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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70L:70F ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I CENSUS TRACT - <br /> Owner's Name � 17 .Phone <br />�..a Address <br /> city Q/'T <br /> Contractor's Name License #//22 / Phone 3i<F 33 3 <br /> TYPE OF WORK (Check) : NEW WELL /�EEPEN f_1 RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT 1_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK t-6 SEWER LINES �vb _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELDI &D CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE _TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> A omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �rrigation 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: / /r State Work Done <br /> PUMP TtEPAIR: / / State Work Done <br /> ,DFGTRUCTION 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 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 /> 14ELL 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 i : TITLE <br /> ; t . <br /> e (DRAW PLOT PLAN, ON REVERSE SIDE) <br /> PHASE I. yw -: j <br /> �:. FOR DEPARTMENT USE ONLY <br /> s a � / <br /> APPLICATIOI�;:ACCEPTED` BY p s Gam; DATE d� �'° <br /> ADDITIONAL."COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE, III/ INAL INSPECTION n, <br /> INSPECTION BY DATE INSPECTION BY C . DATE fd <br /> L—CALL••FOR-A GROUT-INSPECTION--PRIOZ TO GROUTING AND FINAL INSPECTION. -.. <br />_ E H 1426 5/731M . <br />