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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£.,OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �.3 s�P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> k 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 Disgrict. <br /> JOB ADDRESS/LOCATION Yrs (5' 60 62c_� 6 CENSUS TRACT <br />` Owner's Name tc, Phone <br /> Address . P City ' <br /> Contras"tor. s Na License # / 7,j-f phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/.. / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <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 .,... ; . . i <br /> ��� Cable Tool Dia: of' We11 Excavation O <br /> -.Domestic/private. .... . ' . Drilled Dia. of Well Casing . <br /> Domestic/public Driven, ' Gauge of Casing <br /> Irrigation► Grav61 -Pack 'Depth of Grout Seal <br /> Other -� Rotary Type,of Grout <br /> T Other, Other Information <br /> PUMP INSTALLATION: Contractor L <br /> . .._...Type of Pump C' H.P. / <br /> PUMP REPLACEMENT' State Work -Done <br /> PUMP "tEPAIR:. /. /.- . State Work Done <br /> .DFsTRUCTION'OF WELT:-: 'Well"'Diameter' - Approximate Depth ! <br /> Describe Material and Procedure ' <br /> I hereby •'agree -'to c.oiriO3.y with all. Laws and regulations of the San Joaquin Local Health District <br /> and the .St'ate. of. California pertaining to or regulating we11 ''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-'6f the ;cell And notify they► before 'putting the well in use. The above <br /> information is .true,.to,the best of. my kno I-L-dand belief. <br /> - SIGN .... :. .. .. .. ; _ . .... Qiw LE <br /> _. . (DRAW <br /> LOT T,.PLAN. ON RSE SIDE) <br /> I .. . . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION..ACCEPTED .BY :. . _ . - _-,,.. DATE <br /> ADDITIONAL COMMENTS: ? <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTIO <br /> INSPECTION BY. DATE _... .- INSPECTION BY DATE <br /> .CALL_-F'..OR­-A-GROUT`.INSPECTION...PRIOR-TO..GROUTING-AND-.FINAL.INSPECTIO <br /> E H 1426 �_ , C /7-1-;:.�"-� t <br />