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SAN JOAQUIN LOCAL HEALTH DISTRICT µ <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. 72,-5 ov <br /> gLl?'-(f <br /> X� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueds. --7 <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 Joaqu <br /> County Ordinance No. and the Rules and Regulations of the San Jo uin Local Health District <br /> Av 2 ",qof A4U" <br /> JOB ADDRESS/LOCATIONrow%W <br /> CENSUS TRACT <br /> Owner's Name _�,� � A4 A2F-\] ED Q Phone oq 2 <br /> _3 L 7 <br /> Address SO- PR BSc p`r'�" City <br /> Contractor's Name C15 R p ER License # Phone <br /> TYPE, OF WORK (Check): NEW WELL/ DEEPEN%/ RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER BINES -;- PIT PRIVY <br /> SEWAGE DISPOSAL FIELDT- CESSPOOL/SEEPAGE, PIT f OTHER — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .Ihdustilal Cable Tool Dia. of Well Excavation <br /> ` --Ir6mestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irti3 ation _ravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPT BY- DATE <br /> ADDITIONAL COMMENTS <br /> `-..... - .. PHASE II GROUT INSPECTIO ___ PHAS III/FINALINSPECTION- <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />