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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton Cal <br /> Telephone: Calif. <br /> APPLICATION FOR WELL CON5TORUCTION60R1PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 <br /> YEAR FROM DATE ISSUED <br /> (Complete -In Triplicate) Date Issued <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 e in. compliance with San Joaquin <br /> County Ordinance,-No. 1862 and the Rules is mad <br /> and gul tions of the' San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> t - . <br /> 4' CENSUS TRACT <br /> Owner's Name -- <br /> s Phone <br /> Address <br /> f City <br /> Contractor's Name o 'Act; � <br /> License # Phone <br /> TYPE OF WORK (Check) .- NEW WELL DEEPEN _ <br /> _/ / RECONDITION /-' DESTRUCTION /_7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR /—/ PUMPREPLACEMENT /_7 <br /> Other / -- <br /> DISTANCE TO NEAREST: SEPTIC .TANK <br /> SEWER LINES ,_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD s/?e CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCfiION SPECIFICATIONS <br /> avation <br /> , o <br /> Cable Tool Dia, of Well Exc <br /> Domestic/private � Drilled Diaf Well Casing i <br /> Domestic/public 1 Driven <br /> Irrigation I Gauge of Casing d <br /> Gravel Pack Depth of Grout Seal d <br /> Other i Rotary Type of Grout _ -� <br /> Other Other Information <br /> k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 's <br /> H.P. 0- <br /> PUMP REPLACEMENT: / / State Work Done <br /> J <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply-with all laws and regulations of the San Joaquin Local HeDistrict <br /> alth <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 P <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 /> SIGNED <br /> TITLE C� � -5 -, <br /> (DRAW PLAT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> UPPLICATION ACCEPTED BY <br /> WDITIONAL COMMENTS: ! DATE <br /> PHAS II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY ' _ DATE L�1 -7��=—_ .. INSPECTION BY h <br /> f - DATE <br /> CALL FOR A GROUT INSPECTION- PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 f169v TO <br /> 7172 1M -r� <br />