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SAN JOAQUIN LOCAL 11EALTU DISTRICT <br /> FOF."OFFI�C� USE: 1601;. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �y - 2,15 le.) <br /> -76-43sJ� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued p- - 2 <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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. 1tealth District. t <br /> ,TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name - Phone <br /> Address -- <br /> Contractor's Name License f oPhone ,2 <br /> TYPE OF WORK (Check) : NEW WELL /-�EEPEN '/ / RECONDITION ./ DESTRUCTION /7 <br /> PUMP INST.I�LTATION' / 'L'MP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC T/UNK SEWER LINES PIT PRIVY liz - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ° OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-SPECIFICATIONS ;�� <br /> Industrial fable Tool Dia. of-Well- Excdvation r �' <br /> 4----$omestic/private Drilled Dia. of Well Casing', <br /> Domestic/public Driven G4tuge of Casing <br /> Irrigation Gravel Pack Depth of Grout..-Seal <br /> Other Rotary Type of Grout,3"' _e-7,$A &a `f <br /> Other Other. Information <br /> PUMP INSTALLATION: Contractor µ <br /> Type of Pump <br /> PUMP REPLACEMtNT: / / State Work Done <br /> PUMP 'tEPAIi: ! / State Work Done <br /> DFOTRUCT.ION 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 BAYS <br />' after completion of ray work on a new well, I will furnish the San Joaquin Local Health District a <br /> k 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 <br /> TITLE L- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I 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 /> -- 7 1 lrt <br />