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SAN JOAQUIN LOCAL HEALTH DISTRICT //���►yA� <br /> FOR OFFICE USE:� 1601 E. Hazelton Ave. , Stockton, Calif. SCANNED <br /> Telephone: (209) 466-6781 ' 1 Z-3o <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ']L-Z o P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued q-Zj?.-7z,/ <br /> (Complete In Triplicate) <br /> S <br /> Application is hre y 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 Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION ` f.. CENSUS TRACT <br /> Owner's Name ' Phone <br /> �rrr k ;,,� fi <br /> Address -�� /W aS'[? 'E'==_ City <br /> Contractor's Name License iVX�'Phone .,Z <br /> ry TYPE OF WORK (Check) : NEW WELL, DEEPEN ;/7 .RECONDITION ./-7 - DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 y <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK e�—O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ! <br /> A <br /> Industrial _> Cable Tool Dia. of Well Excavation <br /> _2r, Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J <br /> Irrigation Gravel Pack Depth of Grout Seal ! <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> � 4 <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 m-- 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 he well and notify them before putting the well in use. The above <br /> information is t to t of my owledge and belief. <br /> SIGNED TITLE <br /> (DRA LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Y <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENT <br /> PHA NSPECTIO PHA E FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE ' <br /> i CALL FORWINkECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 4/72 1M , <br />