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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Jtf J`' 4`1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7--7y <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]j and the u nd Regulations of he San Joaqui Local Health District. <br /> JOB ADDRESS/LOCATION � ! ----��'' ti-� E � NSUS TRACT <br /> IROwner's Name Phone '"ate is k7 <br /> Address P �. �_M,��,,, City <br /> Contractor's Name Licen/n "� Phone <br /> TYPE OF WORK (Check) : NEW WELL /_^�DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION J j PUMP REPAIR / j PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ ---ea le Tool Dia. of Well Excavation <br /> �omestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing /0 <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: / J State Work Done �� •,�-,�� �, �; <br /> PUMP REPAIR: / / State Work Done <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 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: 9 i/ 7 .ufs,•dcve� xo E/° <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ! A DATE 16 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M i <br />