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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 �� <br /> FOR OFFICE USE: 1 E. Hazelton Ave. ;- Stnckton, Calif. <br /> a_ <br /> Telephone: (209) 466-6781 73 ---7-70 .V <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 2 3, 141 <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued <br /> S <br /> - -• � (Complete Tri Triplicate) 3 <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. 1862kFE -and the Rules and Regulations of the San Joaquin Local Health District. <br /> h <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT '® 3 40-0�' <br /> Qwner.'s Name Phone ' <br /> Address <br /> City ' . <br /> E Contractor's Name � <br /> License V Phone " <br /> TYPE OF ,WORK (Check): NEW WELL J�qr, DEEPEN.'/-/ RECONDITION /? DESTRUCTION r7 E, <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /� r' <br /> Other �/% <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DIS OSAL FIELD CESSPOOL/SEEPAGE PITIV OTHER <br /> 10, <br /> INTENDED USE I <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing t <br /> Domestic/public I Driven Gauge of Casing j <br /> Irrigation t Gravel Pack Depth of Grout Seal Q <br /> Other Rotary--- Y Type of Grout <br /> _1 Other Other Information " !' <br /> PUMP' INSTALLATION: Contractor 7R <br /> Type of Pump Q !' <br /> t H.P. � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done t <br /> >i <br /> .PESTRUCTION 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 REPO of he well. and notify them before putting the well in use. The above._ <br /> information is t e to th t o my knowledge and belief. <br /> SIGNED TITL _ <br /> (DRA PLOT PLAN ON REVERSE SIDE 6 <br /> PHASE I FOR DEPARTMENT USE ONLY <br />'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i -- <br /> PHAS II GROUT INSPECTION PHASE II FINAL IN <br /> INSPECTION BY 1�-j y zo DATEINSPECTION BY <br /> ATE - <br /> CALL FOR A GROUT INSPECTIflNPRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />