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A/o`' fin'' <br /> SAN JOAQU N LOCAL HEALTH DISTRIC <br /> FOR OFFICE'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� Z � r 91N <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 ,23- 'l2- <br /> (Complete In Triplicate) <br /> Application is 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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> 1k ' <br /> Contractor's NameLicense_#// 3,;? Phone S' , sHy� <br /> TYPE OF WORK (Check)t----NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <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 .•A <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 INS <br /> TALLATION. Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> -Iffi3TRt3CTION 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 true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> DRAW .PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY cJ: DATE � -22 72- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II,I/.FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ 4/72 1M <br />