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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:OI-PICE USE, : 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> H <br /> �'./ (Complete In Triplicate) <br /> cation -is hereby-made- to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worts herein described. ' This application is made in compliance with Sant Joaquin; <br /> County Ordinance .No. 1.862 and ,the Rules and Regulations of the San Joaquin Local Heath District. � <br /> JOB ADDRESS/LOCATION Ct I/ C a �/ %} &/-.F-1,+" NSUS TRACT <br /> Owner's Name rL A G � Phone <br /> Address © Z:e R City <br /> Contractor's Name License # Phone <br /> C9 i <br /> N <br /> TYPE OF WORK (Check) : NEW WELL .X DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � r <br /> Industrial. Cable Tool Dia. of Well Excavation 1 i <br /> Domestic/private Drilled Dia. of Well Casing if <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump 7--If H.P. <br /> PUMP RFPLACENMNT: / / State Work Done <br /> PUMP UPAIR: /-7 StAte Work Done <br /> .DFCTRUCTION 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 /> 4 <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 there before putting the well in use. The above � <br /> informatio is true to t4 best of my knowledge and belief. <br /> SIGNED �C 2[r-� _ TITL <br /> ' (Dt2AW PLOT PLAN ON REVERSE SIDE) 4 <br /> 3 FO DEPARTMENT USE ONLY I <br /> PHASE I = <br /> APPLICATION ACCEPTED .B �, DATE <br /> ADDITIONAL COMMENTS: / <br /> -'PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . ' . . . DATE INSPECTION BY DATE -4 -^1,?2-. - <br /> CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M ,.+ <br />