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SAN JOAQUIN LOCAs. 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. /36 <br /> ' THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date .Issued <br /> (Complete In Triplicate) <br /> Application is hereby madeEto- 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 Joaquii <br /> County Ordinance No. 1862 and tth Rules' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /oZ90z�, CENSUS TRACT <br /> Owner's Name Phone 00 <br /> Address City : <br /> Contractor's Name ' License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / . PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER `LINES PIT PRIVY �7 <br /> ' SEWAGE DISPOSAL FIELD 'S CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation m <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public V Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> i Other ;Other Information <br /> PUMP INSTALLATION. contractor , <br /> Type o€ Pump '' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: 4* °• /. / _,�State_Work .Done_ - <br /> : ,DESTRUCTION OF WELL: We11fDiameter Appro im to Depth <br /> . Describe Material and Procedure <br /> ' t <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 worklon 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 'b st of my knowledge and belief. <br /> SIGNED / 4 TITLE <br /> (DRAW,'PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f' <br /> APPLICATION ACCEPTED BY DATE 41 A9 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II ROUV INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY iDATE INSPECTION BY DATE <br /> CALL FOR A GROUT_ INSPECTION .PRIOR TO GROUTING{AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />