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��''y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 F CE E: 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 /> 5.-lu- � <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. 1862' and the R e and . agulations of the San ,Jo 'quin ocal Health District. <br /> JOB ADDRESS/LOCATION <br /> US TRACT <br /> Owner's Name <br /> Phone <br /> Address 3 f fr ' <br /> City .cP �_ <br /> Contractor's Name. <br /> License #/ -_phone 7 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other / / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK I EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' <br /> OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � F <br /> Industrial Cable Tool Dia. of Well Excavation <br /> � i <br /> Domestic/private ..Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> __�V Irrigation Gravel Pack Depth of Grout Seal <br /> Other f Rotar <br /> y Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Can tractor ^� <br /> t� <br /> Type of Pump .� 'T+.t_r ` n� <br /> f H.P. <br /> PUMP REPLACEMENT: % State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,PEST_RUCTION OF WELL: Well--Diameter <br /> Describe Material and Procedure 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 knowle ge an belief. <br /> SIGNED f �" <br /> ` TITLE <br /> (D W OT LAN ON R FRSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHA I FIN INSPEC <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE j <br /> CALL FOR A GROUT INSPECTION PRiOR. TO GROUTING AND FINAL INSPECT <br /> E H 1426 <br /> 7/72 1M <br />