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SAN JOAQUIN LOCAL HEALTH DISTRICT 1' <br /> t7 O1'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?V_ 2 2 940 <br /> A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 <br /> R gulat_qns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name A1l '2 Phone <br /> Address /''� .06 6&L"rhT a4r — City A-11" <br /> Contractor's Name _n 43-, 4L36 4;nT,a C. License #� PhoneFA3- <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION I / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Domestic/private Drilled Dia. of Well Casing OCA <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �C Rotary Type of Grout C.�_ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State..,Work Done <br /> PUMP 'ZEPAIR: / j State Work Done <br /> DF�TRUCTION 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART ANT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II RO IN, E ION PHASE /FINAL INSPECTION <br /> INSPECTION BY - � 1! INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 5/731M <br />