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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 iF <br /> (Complete In Triplicate) ' <br /> Applicationxis 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 Joaquin� <br /> County Ordinance-No.- 1862 and the Rules and Regulations of the San Joaquin Local Health-District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> J <br /> Contractor's Name ,1 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /�j DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION I I 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing E <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal s <br /> Other Rotary Type of Grout ; <br /> -w 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 4 <br /> Ir <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ^� Describe Material and Procedure C <br /> N <br /> I hereby agree to comply with all laws -and regulations of the San Joaquin Local Health District <br /> and the State �o€ 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 PEOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �7P DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION P SE I F'IN INSPECTIO ' <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROU' INSPECTION .PRIOR TO GROUTING AND FINAL INSP TION w <br /> E H 1426 7/72 1M <br />