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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS=t11g14 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby ;bade 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 ipaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONy {!/ ��'L CENSUS TRACT <br /> Owner's Name z=%% Phone/_/�j r <br /> Address <br /> 1 f 7 city u <br /> Contractor's Name� �� License .�_T_5Phon�eZP'Z ^~ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ J RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> k <br /> I 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 C <br /> j 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 Don <br /> PUMP-'REPAIR: State Work Done Y - <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 /> 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. ,l <br /> SIGNED h, r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- -- - <br /> APPLICATION ACCEPTED .BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FNAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION B_y7T,,zDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />