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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> p Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ ti <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> f (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 Joaquit <br /> County_Ordinance No. 1862.and• the Rules and Regulations of the San Joaquin Local Health <br /> ��Z:C��I�''•-SA f�c� �e� ,z, District. <br /> ' JOB ADDRESS/LOCATION ' i-7 <br /> CENSUS TRACT <br /> Owner's Name <br /> ' Phone <br /> Address � <br /> City <br /> Contractor's Name !� <br /> License # rd jo Phone <br /> ii <br /> TYPE OF WORK (Check): NEW WELL /..� DEEPEN_/_� RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / T" -- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES-D PIT PRIVY <br /> CESSPOOL/S -- j <br /> SEWAGE DISPOSAL FIELD PIT OTHER ;' <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SFECIFICATI <br /> Industrial Cable Tool ONS <br /> Domestic/private <br /> Dia, of Well Excavation <br /> �( Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casin <br /> Irrigation g <br /> Other Gravel Pack Depth of Grout Seal , <br /> Rotary ---- �- _ <br /> Y Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor v <br /> Type of Pump <br /> H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APProximate Depth t <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.completioin 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 the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT. PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> E H 1426 <br /> 7/72 1M C <br />