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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Of. OT'FICE US1:: 1601 E. Hazelton Ave, ,. Stockton, Calif <br /> Telephone: (209) 455--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `:J- �.P <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued --�O <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. 1562 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,p CENSUS TRACT <br /> Owner's Name �< Phone <br /> Address 1/ J044 City 001 7 <br /> Contractor's Nam .c„ License 4� l�3 7 rPhone C -X- <br /> TYPE OF WORK (Check): NEW WELL / j DEEPEN f-1 RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /7 So s At,'OP -- r^` ` e ewj2 <br /> 74 G <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 /> � [ <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 /> E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP TtEPAIR: / / State Work Done Szw� <br /> 74-2� j.. <br /> DF�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 p the well in use. The above <br /> information true to the best of my knowledge n b 'ef. <br /> SIGNED <br /> DRAW PLOT Pty ON REVERSE SIDE) <br /> FOR DEPXRTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 30 <br /> ADDITIONAL CO►MNTS: <br /> PHASE II ROUT INSPECTION PHAS /FINAL INSPECPi N <br /> INSPECTION BY DATE INSPECTION BY DATE 6 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 _ 5/731M <br />