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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal-if. <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 Health District. <br /> JOB ADDRESS/LOCATION JS 7 S,� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name _- /, �� �� � � ' License AJ p/a. Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / DESTRUCTION /- <br /> PUMP * AL <br /> INSTLATION / / PUMP REPAIR /� PUMP REPLACEMENTOtherk <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 /> Oq <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing a w <br /> Domestic/public Driven Gauge of Casing _. 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other } Rotary Type of Grout T. <br /> Other Other Information n <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PMP-REPAIR: / State Work Done a <br /> ,DESTRUCTION 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 t b st of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �r <br /> APPLICATION ACCEPTED BY L DATE /Z /� y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />