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{ <br /> G - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FWOFFIC U 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 FROM DATE ISSUED Date Issued /�-/Z <br /> (Complete In Triplicate) <br /> t 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 theRulesan Regulations of•the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> �__ �S C ��._. ' <br /> Owner's Phone <br /> Address � -�' j City �c <br /> Contractor's Name License lfOt e Phone�� y <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / CONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6.0 'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD; ,�,— CESSPOOL/SEEPAGE PIT OTHER <br /> R INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI 5 <br /> Inaustrial Cable Tool Dia. of Well Excavation <br /> 4_15omes Drilled Dia. of Well Casing- <br /> Domestic/public <br /> asing Domestic/public ,k .Driven,, Gauge Casing <br /> Irrigationo. 'Gravel` .ack Dept of Grout S 1 <br /> f / �. . <br /> 4 Other. �• � _K tary:, 1 Typ/d -of,Grout _ Ao"C. <br /> b ..Others Other Information' --A-�� <br /> _` / ti `• N <br /> PUMP INSTALLATION: tractor <br /> T/IlDia <br /> Pump H.P. <br /> PUMP REPLACEMENT: ` ate Wor one ' <br /> PUMP REPAIR: 4 <br /> /St' <br /> ate W Ok Done <br /> .DESTRUCTION OF WELL: y Wne, Approximate-Depth <br /> Describe kA' rial 4►d Procedure O <br /> I hereby agree to com/pl7y_with 11 aws d regulations of the San Joaquin Local Health District ( <br /> and the State of California per ing,,% o 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 /> I inf6rmatio is/true to the t of�my knowledge and belief. <br /> f <br /> SIGNS t _TITLE-, y <br /> (DRAW-PLOT PL V d QLr <br /> h ^x FOR DEP USE ONLY <br /> PHASE I ; ., .. , . . •.'.. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:_;.NTS.:___ - <br /> '�PHASE II GROUT IN8TECTION '.PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION 'BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />