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SAN JOAQUINa-LOCA-h HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (20,9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��3 93 G) <br /> �3 s-Y y�° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 Joaq Local Health District. <br /> JOB ADBR 3S/LOCATION .S' i' CENSUS TRACT <br /> Owner's Name Phone <br /> Address ® 1- 4';j0 City sleqa� <br /> l _ I' r� <br /> Contractor's Name /" '0011 License A-9Phone <br /> I <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ' Other J"� <br /> DISTANCE TO NEAREST: SEPTIC TANK T� SEWER LINESPIT PRIVY !2-,_J <br /> SEWAGE. DISPOSAL FIELD -- CEAJIPOM/SEEPAGE PIT.pfd ie-OTHER -� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable`Tool Dia. of Well Excavation <br /> �- Domestic/private iDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 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 /> PUMP REPAIR: / / State Work Done— <br /> ,DESTRUCTION <br /> ESTRUCTION 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 furntish.,the San' Joaquin Local'Health District a <br /> WELL DRILLERS REPORT of the well ana_�notify -them before putting -the well" iri use. The above <br /> information is true to the best of my knowledge and belief. <br /> k <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,z <br /> ADDITIONAL COMMENTS: <br /> PHAS GROUT INSPECTION PHASE II aINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSP CTION .PRIOR TO GROUTING AND FINAL INSPECTION'. <br /> E H 1426 7/72 1M <br />