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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF CE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> FOR <br /> 17 <br /> THIS PERMIT EXPIRES` 1 yEA111 FROM DATE ISSUED <br /> Date IssuedZ3/-�3 <br /> (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 Joaquin <br /> County Ordinance No. .1862 and the Rules-and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name : <br /> Phone <br /> Address 7 7� y�r, <br /> � -� City EJ�'y�r�t/ � <br /> Contractor's Name t <br /> LicenseVf Phone ' ` <br /> TYPE OF waRx check} : <br /> ( NEW WELL/ / DEEPEN / J RECONDITION /? DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `f <br /> OSPIT PRiVy Jr <br /> SEWAGE DISPAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irri ation <br /> $ Gravel Pack Depth of Grout .Seal, <br /> Other Rotary Type of Grout <br /> Other <br /> Other Information ' � <br /> i <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. 1 � <br /> PUMP REPLACEMENT: State.Work Done <br /> PUMP REPAIR: / / State Work Done <br />.DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 thebbst of my knowledge and belief. <br /> 5 <br /> SIGNED _ TITLEL�(� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A 'GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br />