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SAN JOAQUIN LOCAL#HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,, Stockton, Calif. <br /> Telephone:' (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862• aind rhe 'Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , ► <br /> CENSUS. TRACT' <br /> - a <br /> Owner's Name 1' r <br /> Phone _ ! <br /> Address Cit <br /> y <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / yDEEPEN / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION UMp REPAIR / / PUMP REPLACEMENT J /" <br /> Other -- <br /> DISTANCE TO NEAREST: SEPTIC TANK d! SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _Z,)L,)/ CESSPOOL/SEEPAGE PIT- / �/'gTHER <br /> INTENDED USE _ 2 S:- k ` s -G X2cj> c <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia,#tof Well Excavation ' <br /> _ <br /> Domestic/private .. Drilled Dia. of Well Casing <br /> Domestic/public, Driven Gauge of Casing W <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Other Rotary Type of'R Grout C, x <br /> Other Other Information <br /> r � . <br /> PUMP INSTALLATION: Contractor <br /> TypeofPump H.P. <br /> PUMP REPLACEMENT: <br /> /Z�KS tate Work Done <br /> PUMP REPAIR: /% State Work Done <br /> DESTRUCTION-.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 /> ind 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 /> TELL DRILLERS REPORT of the well and notify them before putting the 'well, in use. The above ; <br /> Lnforma o is true t the best of my knowledge and belief. <br />>IGNED "rte <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />?RASE I <br /> IPPLICATION ACCEPTED BY DATE V'/ i <br /> IDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE t <br /> CALL FOR A GROUT. INSPECTION -PRIOR TO GROUTING AND FINAL, INSPE ION. <br /> E H 1426 7/72 IM C <br />