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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOF.'OkTCC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- SIJ b) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued D /f- -T <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District for a permit to construct <br /> and/or`i-tis tall 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 health District. <br /> 1111`.i111111111�11111. '11 11 - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> j <br /> © ' U <br /> Sll <br /> Owner's Name Phone <br /> City ' <br /> Address Z <br /> Contractor's Name ^ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL li--T' DEEPEN /7 RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PL-mp REPAIR / / PUMP REPLACEMENT /7 <br /> Other ./ 1 <br /> DISTANCE TO NEAREST: SEPTIC TAiNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �a Ie Tool Dia. of Well Excavation 1 <br /> bmestic/private Drilled Dia. of Well Casing n <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Other Rotary Type of Grout _ ;- ,- <br /> w Other Other Information <br /> PUMP INSTALLATION: Contractor . <br /> k H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMPY UPAIR:,,,,i / / State Work Done <br /> # pFI-TRUCTION 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 belief. <br /> i <br /> j SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> i APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> - PHASE III/FINAL INSPECTION <br /> �,P�'1-IASE II GROUT—INSPECTION <br /> INSPECTION BY DATE _/9 9-Z,3 _ INSPECTION BY DATES - <br /> , CALL FOR,A_GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - -- W .-- 5/731M <br />