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60 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Of. 01"Fl L USE: V/ 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 �c7S <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 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/ CENSUS TRACT <br /> Owner's NamePhone zv !z -- <br /> Address City <br /> Contractor's Name ,''� d S License 4� T�hone [� <br /> TYPE OF WORK (Check) : NEW WELL /P—< DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKQ.i SEWER LINES PIT PRIVY // <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT j�/� OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION �SiPEECIIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing rj <br /> Domestic/public Driven Gauge of Casing �� <br /> Irrigation Gravel Pack Depth of Grout Seal 7 <br /> Other Rotary Type of Grout ^— <br /> Other Other Information <br /> 40S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'CEPA IR: /--/ State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply with all laws and regulations of the San 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 /> 14ELL 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 /fj DATE 9 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / / INSPECTION BYDATE7-L <br /> ��=17 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />