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r tZ <br /> SAN JOAQUIN LOCAL HTALTH DISTRICT <br /> '` FOIt OFFICE 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 �� 7' _�L <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 incomplia <br /> County Ordinance�No. 1862 and nce with San Joaquin <br /> :the Rules and Regulaiions. of the San Joaquin Local Health District. <br /> k •• .4. ., ., , <br /> JOB ADDRESS/LOCAT N � " <br /> CENSUS TRACT <br /> Owner's Name -` <br /> Phone <br /> Address <br /> City . <br /> Contractor's Name a <br /> License �_ O_j Phone . '� 7��1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION 17 <br /> PUMP INS T LATION '/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> E� <br /> DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndCONSTRUCTION�SPECIFI ATIONS <br /> ustrial Cable Tool Dia. of Well Excasing <br /> avation <br /> ,< Domestic/private t Drilled <br /> Dia, of Well C <br /> Domestic/public * Driven Gauge of Casing <br /> OGravel - <br /> Irrigation Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> .PUMP REPLACEMENT: / / State Work Done <br />, PUMP. REPAIR:_ - <br /> -� /-7 -St,te7Work,Done-,.. . <br /> ;DESTRUCTION OF WELL: Well Diameter y Approximate.`Depth v, <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 b ief. <br /> SIGNED F <br /> TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I ,I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE S'-/, - 7' <br />.ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 , 4/72 IM <br />