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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 T <br /> F-- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) a permit i <br /> Application is hereby made to the San Joaquin iLsIrication <br /> occallat Dismade trict aV'DinrcampliancetwithnSa:tuJoaquin <br /> and/or install the work herein des ribed. <br /> es iie' of the San Joaquin Local. Jleal.th District. <br /> County Ordinance No. <br /> CENSUS TRACT s <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name r <br /> ! c <br /> � City ; <br /> 'z� <br /> Address <br /> .� License 4� Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN 1 / ON REPAIRRECONDITI/ // PUMPEREPLACEMENT�/�T <br /> PUMP INSTALLATION I P6` ' . <br /> Other <br /> YPIT PRIVY <br /> If DISTANCE TO NEAREST: SEPTIC TANK �j J SEWER LINES PIT <br /> PIT OTHER <br /> I SEWAGE DISPOSAL FIELD <br /> INTENDED USE <br /> TY E. OF WELL CONSTRUCTION SPECIFICATIONS <br /> IAj <br /> ndustrial Cable Tool Dia. of Well Excavation <br /> -�— Dxilled Dia. of Well Casing <br /> Domestic/private <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 /> INSTALLATION: Contractor �' <br /> i PUMP H.P. <br /> Type of Pump <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> kPUMP 'REPAIR: / / State Work Done <br /> Approximate Depth <br /> I ,DFCTRUCTION OF WELL: Well Diameter <br /> $ Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local ilealth District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ii after completion of my work on a new well, I will -furnish the San Joaquin Local Health District <br /> } WELL DRIjLEZS REPORT of the well and notify them before putting the well in use. The above <br /> informat Y t t the best of Tay knowledge and belief. <br /> a <br /> TITLE a <br /> SIGNER <br /> T.T. (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY p 1� <br /> G PRASE I DATE <br /> APPLICATION ACCEPTED -BY <br /> ' ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE S"- <br /> ' INSPECTION BY DATE rS�' 3' 7 `7� <br /> CALL FOR A GROUTINSPECTIONPRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731H <br />