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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI�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 1 YEAR'IFROM DATE "ISSUED Date Issued � Z_ <br /> (Complete In Triplicate) i <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. 1 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB 'ADDRESS/OCATI Q� `lI 5 r CENSUS TRACT <br /> Owner's Name / � ` _ Phone <br /> Address �l 1-. _.. U�-� EELCity <br /> Contractor's Name Q License �� Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ I DEEPEN / / RECONDITION I�I DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I�T <br /> • .� Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWkE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDEDUSE TYPE OF WELL "Jr� CONSTRUCTION, SPECIFICATIONS )IJ <br />` Industrial Cable Tool `�'f'Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> YZrrigation..- `Y� r -- _Gravel;I'ack'._ Depth�o. ;GrautYSeal, - -- - - �✓J <br /> Other =Rotary Type of Grout <br /> Other Othe InformationA <br /> i t <br />! 1, a-/ <br /> PUMP INSTALLATION: Contractor Ail P0FV <br /> Type of Pump EEP NIZ, H.P. ' <br /> r PUMP REPLACEMENT: / / State Work Done A.� - A <br /> r <br /> PUMP- REPAIR: Sta-be,Work:Done-: - <br /> � s <br /> ,DESTRUCTION OF WELL: We-1-1—Diameter Approximate Depth <br /> �. Describe Material and Procedure, <br /> I hereby agree to -eomply' with all laws and regulations� rof the San Joaquin Local Health District <br /> M .and the State of ;California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion"of-my-wo'rk 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 F <br /> (DRAW PLOT PLAN ON REVERSE,,SIDE).-, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �' ' ✓ "`. <br /> APPLICATION ACCEPTED. BY r �� ' '" DATE , - .� <br /> ADDff109AI:COMMENTS t- �f - ' <br /> --Y-- ---PHASE-•II-GROUT YN�SPECTYON- - -� - �--�----�P - I—FINAL INSP-ECTION.-�-- -- - <br /> INSPECTION BY DATE INSP ION BY DATE - 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE <br /> E H 1426 4/72 1M. <br />