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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 /> PLICATION FOR WELL CONSTRUCTIO ',OR PUMP PERMIT Permit No. 7 Z 6/ O <br /> THIS PERMIT EXPIRES ,l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicatiom4s 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.,theeRules� and Regulations of, the; San-Joaquin Local `Health District. <br /> JOB ADDRESS . . Li J <br /> /LOCATION — CENSUS TRACT <br /> Owner's Name „+ Phone <br /> Address City <br /> Contractor's Name aftyetse # .Phone <br /> f!r ! <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION / 7 DESTRUCTION/7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT //�'�n <br /> other. /I <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> PUMP INSTALLATION: ContractorAw- <br /> Type of Pumi�� 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 true to the best of my knowledge and belief. <br /> i <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II OUT INSPECTION PHASEI FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE 2/ 7. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION., z� <br /> Z9 <br /> _ _ �. <br /> E H 1426 4/72 <br />