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U <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> iOF-OFFICE USE: 1.601 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 <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Realth istrict. <br /> JOB ADDRESS/LOCA ` �' �y,ti�. ry � !� /.3.y .G 'ces �a 7� iC . S TRACT <br /> Owner's Name r Phone <br /> Address4 Ca ty <br /> Contractor's Mame A,/l, dsresx (Zz(� zZl-, License <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -f—/ RECONDITION <br /> (/ DESTRUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ©Q / SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ` <br /> 0 estic/private Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation �- avel Pack Depth of Grout Seal <br /> Other T4,,,, Rotary Type of Grout <br /> Other Other Information <br /> e � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFRTRUCTION 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 them before putting the well in use. The above <br /> information is true to the best of my knowledge and bell-ef. <br /> SIGNED , TITLE <br /> Ld- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT U8E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �zyILZ:� DATE 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-S <br /> CALL 'FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 A im <br />