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P <br /> SAN JOAQi3.xN LOCAL HEALTH DISTRICT <br />,. fOF. OFFICE USE: Pill <br /> 1601 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby m--de to the San Joaquin Local Health District for a permit to construct F <br /> and/or install the wa ,$herein described. ' This application is made i • compliance with Sant Joaquin <br /> County Ordinance No 1852 and the Rules and Regulations of <br /> the San Joa in Local: Health District. <br /> •.A 3/ r � CENSUS TRACT , <br /> JOB ADDRESS/LOCATI <br /> Owner's Name Phone <br /> Address j6, City , <br /> ij <br /> Contractor's Name A Licensed Phone ' <br /> I1 TYPE OF WORK (Check) : NEW WELL / DEEPEN -/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLUMP REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other <br /> -'v <br /> IN <br /> DISTANCE TO NEAREST: SEPTIC TANK CQQ0 EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> 4 d� <br /> i INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> In ustrial able Tool Dia. of Well Excavation <br /> or <br /> I estic/private : Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -71 <br /> - <br /> �rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information EE 4 <br /> ij <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> --PUMP 4REPLACEMENT: I / �/ - State Work Done �--�-�=-�� - ^�'��-'� T '" "`- ' II.� � • <br /> i <br /> PUMP `tEPAIR: / / State Work Done <br /> I <br /> DFCTRUCTION OF WELL: ' : Well Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> ly with all laws and regulations of the San Joaquin Local Health District: <br /> I hereby agree to conip, <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> l after completion of my work on anew 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 true to .the bes of my knowledge and belief. <br /> iTITLE ' <br /> SIGNED A) <br /> (D OT PLAN ON REVERSE SIDE) <br /> jOR DEPARTMENT USE ONLY <br /> L�I <br /> � PHASE I DATE � J <br /> APPLICATION ACCEPTED BYi <br /> f ADDITIONAL COMMENTS: Z <br /> PHASE IIIA dw5ft INSPECT10 PRASE ZII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> s V u IA9A Ili --- 5/73zrt -- <br />