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OV <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fO�.,OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� rF/ld <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 11-S-Z�4- <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 wade in compliance with San Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION �� ��� (y/Yl. / CENSUS TRACT <br /> Owner's Name Phone <br /> Address City . <br /> Contractor's Name 15 License 4�� Phone � I <br /> TYPE OF WORK (Check) : NEW WELL ,& DEEPEN '/—/ RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT j- <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> \ I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private- _ Drilled Dia. of Well Casing _ <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 ' C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP UPAIR: j / State Work Done <br /> i <br /> I <br /> ,DFCTRUCTION 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 thein before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED .BY DATE. <br /> ADDITIONAL COMMENTS: �� -, (. .- c� :•/r!rerJ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY+ DATE INSPECTION BY DATE /0— `� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1� 2r 9 r_nr- C� /7-A <br />