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C ll N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR OFFICE USE: 16( Hazelton Ave. , Stockton, Cain-. <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) <br /> Application .is hereby made to .the San Joaquin Local Health District for a permit to construct <br /> and/4r 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 /> 4 <br /> _JOB ADDRESS/LOCATION ]S CENSUS TRACT <br /> Owner's Name. . Phone - <br /> 7 <br /> City <br /> Address . . <br /> Contractor's Name License # :X_? / ��Phone 7� <br /> TYPE OF WORK (Check): . NEW WELL/ / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . SE R n,TNES 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 Casing <br /> F Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> Other Rotary Type of Grout <br /> Other .Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> 1 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 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 _ TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �;, DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _�Q DATE <br /> �E <br /> CALL_ FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 4/72 1M <br />