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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 3.601 Hazelton.-Ave.', Stockton, Calif. <br /> elephone:. . (209) 46b-6781 <br /> APPLI ATION+ FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No 7 30(l to <br /> Y <br /> THIS RMI T ,EXP AES 1 YEAR•:FROM DATE ISSUED Date Issued <br /> "(Complete .Ih, Triplicate} <br /> Application is hereby made to e San-Joaquin:Local Health District for a permit to construct <br /> and/or install the work herein-described. Thi.s,.application is made in compliance with 'San Joaquin <br /> County Ordinance No;>:1862. and ,t ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> # r ' <br /> Owner's Name , I <br /> Phone <br /> Address X� � �y�{ <br /> City <br /> Contractor's Name ®� /� �<.� License &&07fV Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ' _ <br /> / / RECONDITION '/_/"°"DESTRI3CTION/� <br /> AL <br /> PUMP INSTALLATION —PUMP REPAIR / / 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 <br /> Domestic/private Drilled Dia, of Well CasingDomest , <br /> Irrigation <br /> Driven Gauge of Casing ,^ cw- <br /> Irrigation Gravel Pack Depth of Grout Seal- �p � , { <br /> Other Rotary Type of Grout Or-... <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' <br /> H.P. - <br /> PUMP REPLACEMENT: / / State 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 /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of m work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP of the well and notify them before putting the well in use. The above j <br /> informatio- ue to the-best-of-,,my knowledge and belief. <br /> SIGNED TITLE - I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) + <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4 <br /> PHASE GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY or DATE 10 of 7 INSPECTION BY DATE 3`- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />