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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf.• 01IFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1��trJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��, <br /> (Complete In Triplicate) <br /> Application is hereby rade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is wade 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 CENSUS TRACT <br /> Owner's Name _ ,'-• ,.,.� Phone " / <br /> r <br /> Address f y <br /> Cit ar * <br /> . .,' <br /> License � C'' � -X Phone <br /> Contractor's Name " <br /> 41 <br /> TYPE OF WORK (Check) : NEW WELL 1 DEEPEN '/-7 RECONDITION / / DESTRUCTION /—T <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT I=T <br /> Other <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 r _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal y. -t, <br /> Other Rotary Type of Grout �• <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -"r,;,. f _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFgTRUCTION 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 truce-to the best of my kn9wledge and belief. <br /> 4PTITLE rle. <br /> SIGNED �_ .* :»� t ^c' r' <br /> LOT PLAN ON REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE I � 14 9";APPLICATION ACCEPTED BY DATE -4--= <br /> ADDITIONAL COMMENTS: 711 <br /> f-- <br /> PHASE II G49PAKCTIpf PHASE /FIN INSPECTION <br /> INSPECTION BY ATE INSPECTION BY -DATE '.^ V <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />