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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued %�� <br /> (Complete In Triplicate) <br /> Applicatio s 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 ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , ' CENSUS TRACT S� <br /> Owner's Name � _, �� �G Phone <br /> Address _ 2 �� Cit <br /> jor <br /> Contractor's Name �V ,License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN//_—[ RECONDITION /_-7 DESTRUCTION /-7 1 <br /> AL <br /> PUMP INSTLATION REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other f-1 <br /> oQ <br /> DISTANCE TO NEAREST: SEPTIC TANK _.r�— SEWER LINES ,� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information A <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 i true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> ( W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '� DATE 7�3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA$ III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7- 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 im <br />