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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 16017E. Hazelton Ave., Stockton, Calif. <br /> _ - Telephone'; (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Date Issued <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. <br /> County OrdinThis application is made in compliance with San Joaquin <br /> ance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j / �Lc <br /> CENSUS TRACT �r <br /> Owner's Name <br /> .� <br /> Phone <br /> Address / / � , �- <br /> • City <br /> Contractor's Name -- <br /> �. [.�. License # Phone .�?_c3Y�S�2 <br /> TYPE OF WORK Check): <br /> NEW WELL EEPEN /? RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /71 PUMP REPAIR / PUMP REPLACEMENT 1-7 . <br /> Other /`/ ' ''„ -- c3 ,. 0L,. <br /> DISTANCE TO NEAREST: + SEPTIC TANK SEWER LINES <br /> rSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> — <br /> X ., k, OTHER <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> . k:� Domestic/private Drilled Dia. 'of Well Casing y ii / <br /> Domestic/public: Driven, Gauge of Casing 42 7 <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Other /'�1 <br /> (/'Rotary Type of Grout <br /> -- .` Other Other Information <br /> f PUMP INSTALLATION, L \ x..•\ <br /> Contractor <br /> Type of Pump <br /> 1 r v H.P. <br /> PUMPRCEMENT: k ' <br /> � EPLA� / / State Work Done <br /> PUAD' REPAIR; _ <br /> _ / / State Work Done t <br /> I,RESTRUCTION OF WELL_: . , Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and re uiation <br /> rict <br /> Sanoaq� <br /> and the State of California pertaining to or regulating owellf -theconsatruction.LocaWithinaFIFTEEN DistDAYS <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 <br /> information 'is true to the best of my knowledge and belieftting the well in use. above <br /> SIGNED TITLE <br /> i DRAW PLOT PLAN ON REVERSE SIDE I <br /> PHASE I FOR DEPARTMENT USE ONLY J <br /> APPLICATION ACCEPTED By <br /> �� , <br /> ADDITIONAL COMMENTS: DATE '.2 <br /> PHASE II GROUT INSPECTION <br /> IN <br /> INSPECT <br /> ON <br /> INSPECTION BY DATE — �•- 7j INSPECTI �i <br /> DATE # <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AN INAL_INSpZC.TSON__,,, <br /> 1.4.26--- . <br /> _' 7/72 1M �� ' <br />