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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.�OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> "r Telephone: (209) 466-6781 ' <br /> -41%CE-- PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED ii Date Issued <br /> (Complete In Triplicate) i� <br /> Application is hereby made to the San Joaquin Local Health District for a �lpermit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaqui.ni <br /> County Ordinance 'No. 1862 and the Rules and Regulations of the Sari Joaqui M Local lieal.th District. <br /> .TOB ADDRESS/LOCATION IS aF CENSUS TRACT <br /> � <br /> - 4 Phone <br /> Owner's Name "� . r -10, <br /> i !� r <br /> ` r <br /> fl <br /> Address <br /> City <br /> Car=96tor s Name W <br /> .w <br /> TYPE OF WORK (Check): NEW WELL -/ / DEEPEN / / RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> .I <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 \ <br />` Domestic/public Driven Gauge of Casing <br /> i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Ocher Rotary Type of Grout <br /> - -Other Other Information <br /> PUMP INSTALLATION: Contractor W <br /> Type of Pump T31-F f H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: J / State Work Done <br /> k <br /> ,DF1zTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> (4 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 /> r WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is true to he best o my knowledge and belief. I` <br /> SIGNED <br /> - TITLE�r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) II <br /> DEPARTMENT USE ONLY t <br /> f PHASE I f� `� DATE <br /> APPLICATION ACCEPTED :BY <br /> ADDITIONAL COUNTS: <br /> pRASE _II GROUT INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE:-; INSPECTION BY BATE <br /> . <br /> 1. ' - <br /> CALL FOR A GROUT- INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �• <br />