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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOf. OI'FICL' 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) -S 3-f 2.a "e5 <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/LOCATIQ CENSUS TRACT <br /> Owner's NameT� /��oPhone <br /> Address Tl� City <br /> � Name -2 a ,Z- l.n � License l8DI�--Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN I I RECONDITION /_/ DESTRUCTION <br /> AL %f <br /> PUMP INSTALLATION /7- PUMP REPAIR I I PUMP REPLACEMENT /- <br /> Other FT 'T1�-x-� 7Zt.� l s 1 .� 4� r i1r��r� l� �j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER QQ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information p� <br /> PUMP INSTALLATION: C - 4 <br /> Type of Pump H.P. A <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> .DFRTRUCTION 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 /> t <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARPENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ^ DATE ------- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II FINAL INSP CTION <br /> INSPECTION BY DATE INSPECTION BY DATZ4-f47-79 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />�. E H 1426 5/731M <br />