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i <br /> 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. ,A71 <br /> i. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7( <br /> (Complete In Triplicate) <br /> Application is hereby made t1 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 Jo a uin Local Health District. <br /> d <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamePhon <br /> Address Gf1. City <br /> Contractor's Name r LicensePhon <br /> t <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /'T RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP I STALLATION / / ' P REPAIR / / P RE C NT /-7 <br /> Other r <br /> DISTANCE TO NEAREST: SEPTIC TAW SEWER L S PIT PRIVY <br /> SEWAGE DI OSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria]. _.Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation 1. Gravel Pack Depth of Grout Seal o <br /> Other 1 Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION-. Contractor <br /> Type of Pump H.P. <br /> E PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> 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 GTITLE <br /> 01VAW PLOT PLAN ON REVERSE SI E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I + <br /> APPLICATION ACCEPTED BY DATE -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE IIIIFIZJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> k <br />