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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F4#..OI?FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _74"-407/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Tssved/O�/_ C-'y/,/ <br /> (Complete <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 SanJdaquin <br /> County Ordinance No. 1 62 and the Rules ao Regulations of the San Joaquin Local: Ileal.th District. <br /> JOB ADDRESS/LOCATION s <br /> CENSUS TRACT <br /> Owner's Name - <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION/—/ DESTRUCTION <br /> PUMP INSTALLATION ,L PUMP REPAIR -/—/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TZliN7KSE,�TER <br /> ER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER [1 r <br /> INTENDED USE s TYPE OF WELL <br /> Industrial, CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 'j <br /> _ Domestic/public Driven Gauge of Casing <br /> y Irrigation Gravel Pack Depth of Grout Seal <br /> Other . <br /> Rotary Type of .:Grout, <br /> Other Other Information <br /> PUMP INSTALLATION:. Contractor ¢ <br /> r <br /> tType of Pupip- <br /> H.F. <br /> PUMP REPLACEMENT: ! - <br /> State �Work Bone � , • <br /> PUMP UPAIR: <br /> State Work `Done <br />.DF5zTRUCTION OF. WELL. Well Diameter <br /> ._. <br /> Describ.LkiterTa1 and Procedure Approximate Depth <br /> I hereby agree to comply with: all;law9­and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or-regulating well construction. Within FIFTEEN DA <br /> YS <br /> after completion of my work on ariga well, I will furnish the San Joaquin Local Health District a � <br /> WELL DRILLERS REPORT of ~the well and riotify them before-putting the well in use. The above <br /> information is true 'to lthe best of my 'knowledge and belief:�. 1 <br /> SIGNED <br /> TITLEft <br /> ( - aa-49-9. AWPLOT PLAN ON REVERSESIDE) <br /> PHASE I [ <br /> T.w - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPT EDrBY I <br /> ADDITIONAL C010JENTS: DATE <br /> .PHASE 11 GROUT INSPECTION P E 11 FINAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE r1� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 + <br />