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s0 -7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X7,3 <br /> F7^7 1`j (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 Jpaquin <br /> County Ordinance .No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> "JOB E DRS%OCATION %J_ �\ 0_ V,.j R C� ' CENSUS TRACT <br /> Phone <br /> Owner's Name - <br /> Address N City 1&s <br /> Contractor r s Name License ��/p � Phone�S�S <br /> TYPE OF WORK (Check): NEW WELL /�/ DEEPEN /�RECONDzTION�!_/ DESTRUCTIONS% ..... <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 fable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing IQ <br /> Domestic/public Driven Gauge of Casing <br /> �xrigation Gravel 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 /> :- /7—State-Work "Done K--4 <br /> DF,TRUCTION 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 /> i <br /> I� SIGNED TITLE <br />( (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED X t— <br /> DATE //-� - � - <br /> } ADDITIONAL CO'3MENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 442 DATE <br /> . ...CALL FOR A GROUT INSPECTION-PRIOR -TO GROUTING AND FINAL INSPECTION. <br /> 5/7 <br /> H 1426 31rtr <br />