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L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: '"16/01 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6731 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q d 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ,�/I , _„_ (a ,1/' CENSUS TRACT <br /> Owner's Name - - Phone �/-”/Vf2 <br /> Address ( City <br /> Contractor's Name �,� ,y." License # L� Phone IrG�S <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <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 CIO <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 f <br /> 7r _771 <br /> PUMP-INSTALLATION: U 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 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 �L <br /> /- �7 Z•c�, ,.� ^tic 1,- "1Z TITLE �' <br /> (DRAW PLO PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS UT INSPECTION PHA SPECTION <br /> INSPECTION BY DATE ��p_�,� INSPECTION BY TE g <br /> 2 _T <br /> CALL FOR SP TION P IOR TO GROUTING AND FINAL INS <br /> E H 1426 4/72 1M <br />