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• <br /> }, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' Lf Stockton, Calif. <br /> F -R OFFICE USE: 1601 E. Hazelton Ave. , Stoc ; <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No- a- `!_3 <br /> THIS ..PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date"Issued <br /> 3 <br /> fs (Complete `In Triplicate} <br /> Application is hereby-made td1the San Joaquin Local Health District fog a �permit to construct <br /> and/or install the work herein described. This application is made in compliance With San . oaquin <br /> County Ordinance"No. 1862`and'^the Rules and Regulations of 'the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION Imn <br /> CENSUS TRACT <br /> Phone 4V2 <br /> Owner's Name <br /> City <br /> Address IS 5 <br /> Contractor's Name �1 <br /> License # �237�3 Phone L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /7 DESTRUCTION 1 <br /> PUMP INSTALLATION / / PUMP REPAIR j/ PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE [DiSPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER • <br /> A <br />} INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private I -� Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other f Rotary Type of Grout C <br /> Other Other Information <br /> iAL <br /> r # <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> f <br /> DESTRUCTION 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 1pertaining 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 best of my knowledge and- belief. <br /> SIGNED TITLE p�„ <br /> 1111 <br /> (D W PLOT. PL ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �(J DATE44 ' <br /> APPLICATION ACCEPTED BY /ti <br /> #ADDITIONAL COMMENTS: PHASE III/F NAL INSPECTION <br /> PHASE II GROUT NSPECTION INSPECTION BY DATE? <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />