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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L'OJ'..OFE'iCE UsE :1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> . . y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issuedc5� �C1 <br /> (Complete In Triplicate) <br /> Application is hereby made t�o, 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 and the"Rilles and./Regulations of the San JoZqui4noSal HeaLth District. <br /> JOBADDRESS/LOCATION l� TRACT ' <br /> Owner's Name Phone <br /> � <br /> Address /' W City �J <br /> Contractor's Name �.N.� License # ?2WtIZ Phone 7,¢eS 3aMT <br /> I <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN/7 RECONDITION_/_/ DESTRUCTION /_7 . <br /> PUMP INSTALLATION / / PUMP REPAIR j / PUMP REPLACEMENT /7 $� <br /> Other" / <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 y "#- <br /> Domes tic/private. <br /> ''Domestic/private.. Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing � r' <br /> Irrigation T Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j 1State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> 3 <br /> • r <br /> ,DF(ZTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' I hereby agree to comply with all laws and regulations of the Sari 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 putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW'PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1�6DATE <br /> ADDITIONAL COMMENTS: G <br /> PHASE II GROUT INSPECTION HASE I FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION DATE <br /> CALL -FOR A GROUT INSPECTION PRIOR TO GROUTING ANIS FINAL INSPECTION. <br /> E H 1426 - K/71im <br />