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FOR OFFICE USE: <br />i <br />SAN JOAQUIN LOCAL ITEALT?I DISTRICT <br />1601 E. Hazelton Ave,; Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7l� <br />7_5 -/34 -;el <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED; Date Issued //-/- 7-2- <br />(Complete,In Triplicate) <br />Applicatiori'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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION ISS PC/ CENSUS TRACT <br />pf <br />Owner's Name - Phone -Z.' <br />Address City <br />Contractor's Name ULicense # one c��KCf COD <br />-TYPE.OF._' ORK (Check):`,, ./ <br />NEW.WELL_/ _ DEEP.EN'X- RECONDITION / / DESTRUCTION- <br />-7 <br />PUMP INSTALLATION / PUMP REPAIR - / I PUMP REPLACEMENT �. <br />Other / / <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Industrial <br />Cable Tool <br />Dia. of Well Excavation <br />�[ Domestic/private <br />Drilled <br />Dia. of Well Casing <br />J E <br />Domestic/public <br />Driven <br />Gauge of Casing 0 <br />Irrigation <br />Gravel Pack <br />Depth of Grout. Seal <br />Other <br />Rotary <br />Type of Grout <br />Z <br />Other <br />Other Information <br />PUMP INSTALLATION: ` <br />C6iitract6f <br />N, <br />Type of Pump_ _ . <br />t /70 H . P . <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />ESTRUCTION= OF WEI,I.: <br />I I State Work Done <br />State Work Done <br />Well Diameter <br />Describe Material. and Procedure <br />Approximate Depth <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. <br />SIGNED <br />PHASE I l <br />APPLICATION ACCEPTED BY I <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE �— <br />TITLE <br />PLOT PLAN ON REVERSE SIDE <br />FOR DEPARTMENT USE ONLY <br />INSPECTION BY <br />DATE JO - 3 0- 2't?-__ . <br />III/FINAL INSPECTION <br />DATE <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 e 4/72 1M <br />