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SA1N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICAT"ON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4�0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (, 3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :end/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/ <br /> LOCATION <br /> CENSUS TRACT <br /> Owner's Name 1 <br /> Phone <br /> Address City <br /> Contractor's Name <br /> war ✓� �., License 4 r.. � .; Phone <br /> TYPE OF WORK (Check) : NEW WELL /- ,� DEEPEN R.kCONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /)C7 <br /> Other / / - — — <br /> DIST, NCE TO NEAREST: SEPTIC TANK — � e WEIt LINES <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE €7F WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial w 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: Contractor <br /> Type of Pump— <br /> — —_ H.P. / <br /> PUMP REPLACEMENT: /k/ State Mork Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diamet.e}: <br /> Describe Material and Procedure Approximate Depth <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 nest of my knowledge and belief. <br /> SIGNED . " <br /> TITLE <br /> (D POT PLAN ON FR ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE �JGR�OUTNSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY r' ATE _ INSPECTION BY s-,..".;:; - <br /> DATE P <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. <br /> E H 1426 <br /> 7172 1M <br />