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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 PUMA PERMIT Permit No. -12-- <br /> THIS <br /> o. -1 <br /> THIS PERMIT EXPIRES I YEAR 'FROM DATE ISSUED , Date Issued <br /> (Complete In Triplicate) '. <br /> ct <br /> Application is hereby made to the San ed.JoaThissaapplal icationealth Distmade inrict r'co pliancea permit twithnSanuJoaquin 4` <br /> and/or install the work herein described. Th PP <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> ,TOB ADDRESS/LOCATION Q �rLaf j <br /> Phone ' _ �- <br /> aF i 1i <br /> Owner's Name <br /> City <br /> Address <br /> n License # Phone <br /> Contractor's Name <br /> TYPE OF WORK -(Check): NEW WELL '/ -/ DEEPEN/ / RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR I/ / PUMP REPLACEMENT /_T <br /> _ 3 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> INTENDED USE _ <br /> Industrial <br /> Cable Tool Dia. of Well Excavation p <br /> Domestic/Private Drilled Dia. of Well Casing <br /> Domestic./public Driven Gauge of Casing �# <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal 1 <br /> Other !; Rotary $ Type of Grout - <br /> Other Other Information` <br /> PUMP INSTALLATION:" .Contractor H.P. <br /> { i'Type' of Pump <br /> i <br /> PUMP REPLACEMENT: '/ / State Work Done <br /> i <br /> PUMP REPAIR: / / State Work Done / 1 <br /> Approximate Depth _ <br /> .RESTRUCTION_-OF•WELL-:-;;;-�.`-We11—Diameter—�:7_-- <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 td. the best of my knowledge and belief. - - <br /> ! SIGNED TITLE <br /> s <br /> (DRAW PLOT AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> J PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE S Z <br /> s ADDITIONAL COMMENTS: <br /> PHASE II ;:GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> DATE INSPECTION BY DATE <br /> INSPECTION BY - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> i E H 1426 <br />