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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> L�� I Ii <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 <br /> permit <br /> E and/or install the work herein described. This application is made in compliancetwithnSan uJoaquin <br /> I County Ordinance' No. 1862 and the Rules and Regulations' of the San Joaquin Local. Health District, <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> city <br /> G Contractor's dame License # ' Phone <br /> ��- V-,5 <br /> TYPE OF WORK Check) ; 1 <br /> 4 { NEW WELL �/ DEEPEN /� RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /,1(/ PUMP REPLACEMENT /_7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br />` J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> 1Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge ofCasing <br /> Irrigation t Gravel Pack .-Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information s y <br /> 's <br /> PUMP INSTALLATION: Contractor c <br /> Type of Pump p <br /> } H.P. � <br /> PUMP REPLACEMENT: / / Sitate"Work Done C <br />- PUMP-REPAIR: f -;. _ r X -s-tate Wor.-k.�.Done 00 <br /> ,DESTRUCTION 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 we11 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 /> {DRAW LOT PLAN ON REVERSE 5ID d <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , / DATE /��4/ y <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION P S FIN INSPECTION <br /> INSPECTION BY _DATE INSPECTION BATE <br /> CALL FOR A GROUT NSPECTIONFPRIOR.TO GROUTING AND FINAL INSP CTIO <br /> E H 1426 -,7j 72 1M <br />