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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -7 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - '-jam <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District Q t ct for a permit to construct <br /> 4 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/LOCATION2a2 <br /> jj &JECENSUS BRACT <br /> Owner's Name 7in i Phone <br /> Address _ cml _ city �- <br /> Contractor's Name License 41 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION fLY PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other /-7 — <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 4 <br /> , Domestic/private Drilled Dia, of Well Casing r <br /> Domestic/public Driven Gauge of Casing ��_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout13NdtAk Ch ell <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 /> ,DEST_R_UCTION 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 />'f 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 k owledge and belief. <br /> f SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN5PE ION. <br /> E H 1426 7/72 1M <br />