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/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFIGE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6. 781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 Joa u <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , O S <br /> + CENSUS TRACT <br /> Owner's Name <br /> Address <br /> '' PhoneCity <br /> ' Contractor's.Name 7zS o� <br /> License !� aWO/O Phone gg�` 07 <br /> TYPE OF WORK (Check):� NEW WELL /7 DEEPEN /_/ RECONDITION / TRUC 0 _; A <br /> PUMP INSTALLATION /? ._. <br /> ` Other / S/ �/ PUMP REPAIR /Lfr-PUMP REPLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> F : SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TY <br /> Ind PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ustrial Cable Tool .•.� <br /> Dia, of Well Excavation <br /> Domestic <br /> /private Drilled Dia, of Well Casing <br /> Domestic/public DrivenO <br /> Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> Other -RotaryV� <br /> Type' of Grout `*. .. .. <br /> Other Other Information <br /> G � .v' .. <br /> PUMP INSTAL ..� , 4 T � <br /> CATION: Contractor S <br /> Type of Pump �. <br /> H.P, <br /> PUMP REPLACEMENT: / / State Work Done ~ <br /> t,PUMP..REPAIR-: <br /> - <br />� <br /> ESTRUCTION OF WELL: Well Diameter �1',vS74�L �''� <br /> Approximate Depth <br /> Describe Material and Procedure <br /> h all laws and regulations of the San Joaquin Local Health District <br /> I hereby agree to comply wit <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 in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDX�d <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED -BY � �- � �� � <br /> ADDITIONAL COMMENTS: DATE r <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHA I AC IN5PEC N <br /> DATE INSPECTIO BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 7/72 1M <br />