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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFIC$ USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7' <br /> 17-:1//J <br /> f 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 /> I County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f JOB ADDRESS/LOCATION <br /> f CENSUS TRACT <br /> Owner's Name <br /> - _ Phone <br /> Address <br /> Z' - City <br /> Contractor's Name <br /> License 6 Phone .� 4/ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /? DESTRUCTION /_7 W <br /> PUMP INSTALLATION / / P REPAIR / —PUMP REP EMENT /? <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / ./ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 belief. v�f� <br /> SIGNED d � <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY E <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 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 <br /> 7172 1M <br />