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1 <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 l YEAR T'RONi DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is: hereby made to the San Joaquin Local Health District tor 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 Ruules, and-Regulations of- the San Joaquin LCa Health District. <br /> JOB ADDRESS/LOCATION � c-C��r , U ' CE SUS TRACT S ZI <br /> F ' <br /> ,Owner's Name Phone '. <br /> Address X City <br /> Contractor's Name License # '�-4 , D Phone X),( <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN '/—/ RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION _K1 PUMP REPAIR/ / PUMP REPLACEMENT <br /> 4 Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> S WAG JISPO FIELD CESSPOOL/SEEPA E PI OTHER <br /> INTENDED USE TYPE OF . L CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ? <br /> E V, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casings <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout T <br /> 0 er 0 Oth r In a mation <br /> PUMP INSTALLATION: Contractor <br /> r <br /> ,n Type of Pump H.P. <br /> Aj <br /> State Work Done r <br /> E <br /> PUMP REPAIR: / / State Work Done <br /> E <br /> ,DESTRUCTION 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 /> informationi, true to t be of my knowledge and belief. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . . DATEF� 7Z- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E`H 1426-' 4/72 1M <br />