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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 . OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77v--21J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .5-,2,,/ <br /> p <br /> (Complete In Triplicate) <br /> Applicatio 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 /> h <br /> JOB ADDRESS/LOCATION If? L-14" CENSUS TRACT <br /> Owner's Name 44 Phone <br /> Address city <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENY- <br /> -7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TAINK 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 62 <br /> Domestic/private Drilled Dia. of Well Casing 6- <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 UPAIR: State Work Done <br /> DFqTRUCTION 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 RE-PORT of the well and notify them before putting the well in use. The above <br /> information is to the b f m ledge a d belief. <br /> WN ' <br /> SIGNED TITLE <br /> SD PLOT PLAN ON REVERSE SIDEL <br /> FOR DEPARTMENT USE ONLY <br /> PdASE I <br /> APPLICATION ACCEPTED BY e. DATE <br /> - <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHAS&JIUFINAL INSPECTI9 <br /> INSPECTION BYDATE INSPECTION BY DATE 10 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPL'WON. <br /> E H 1426 5/, 731M <br />