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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F012 OFFICE USE: 1601 E. Hazelton Ave., . Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION.OR PUMP PERMIT Permit No. 72- <br /> THIS PERMIT EXPIRES "1;' YEAR FROM'-DATE ISSUED Date Issued L- 7- 7l� <br /> (Complete =ln Triplidate) <br /> Application isrhereby 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. -1862 arid•,the .Rules-and Regulations .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /c _ _ U c T�/� CENSUS TRACT <br /> Owner.'s Name <br /> Phone <br /> Address <br /> -_ �_ -_ _C2 City. <br /> Contractor's Name ,+ — � S License # s Phone <br /> TYPE OF WORK (Check) : NEW WELL /p_;-�DEEPEN / / RECONDITION-/_/ DESTRUCTION-/� <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,!J� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , p CESSPOOL/SEEPAGE PIT !oo•-{ OTHER" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> /Domestic/private /Drilled Dia, of Well Casing O <br /> Domestic/public Driven Gauge of-Casing _ <br /> Irrigation Gravel- Pack Depth of',,Grout Seal -T-0 <br /> Other Rotary - - Type of ]Grout _ V,-& ~,P.,/r <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter ` •i, Aproximate __T_ ! <br /> Describe Material and Procedure A I <br /> Y V. <br /> I hereby agree to comply with all laws and regul ions o h oaqui a1 Health District <br /> \1 <br /> and the State of California pertaining to or reg ating 1 tructio ] thin FIFTEEN DAYS <br /> after completion of my work on, a new well, I wit furnis the n Joaquin oci Health District a <br /> WELL DRILLERS REPORT of the well and notify th b fo <br /> y putt' the well in use. The above <br /> information is ue to the best my knowled and b- of <br /> SIGNED _TITLE <br /> (D LOT ILA ON VERSE SID <br /> PHASE I <br /> OR D T T E ONLY <br /> � - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE d <br /> CALL FOR A GROUT INSPECTION,-PRIOR. TO GROUTIN AND FINAL INSPECTION. <br /> H .1426 _ 4/7.2 1M . _ <br />