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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =FTCL `U5'3 „. 1601 E. Hazelton Ave. , Stockton) Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.' WI <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> ;Application is hereby rade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work .herein described. .- This ,application is- trade in compl.iance..with San Joaquin <br /> 'County Ordinance .No, .1662 and the Rules and Regulations of the San Joaquin Local: Health District, § <br /> 7 � / �' <br /> ''`30B ADDRESS/LOCATION CENSUS TRACT k { <br /> F <br /> '`Owner Is Na � ` Phone.. <br /> Address '� _ City ' A <br /> — / 2 ' <br /> �. e� . � Licenser$3� hone��J <br /> Contractor s Nam _ '�, ti �`� --- , <br /> TYPE OF WORK (Check) : NEW WELL //t- DEEPEN / / RECONDITION I I DESTRUCTION /7 <br /> PUMP INSTALLATION / / PL`MP REPAIR /�/ P REPLACEMENT <br /> g <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> <; <br /> 7"-P <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial --table Tool Dia. of Well Excavation <br /> mestic/private Drilled Dia. of Well Casing IV <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 ' <br /> FUME' INSTALLATION; Contractor <br /> i. -- Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: _ - % 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 /> andtheState of Califorii.a 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 aj <br /> ' WELL DRILLERS REPORT of the well and notify them before putting the well in use. The move ; <br /> information is true to the best of my knowledge and belief. <br /> SIGNED c _; TITLE <br /> (DRAW PLOT PLAN ON REVERSV SIDE f , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 5 ' �•, ,�• . nFt <br /> APPLICATION ACCEPTED BY. yi7ATE <br /> ...,: <br /> 'ADDITIONAL CMENTS: ' <br /> PHASE I.I GROUT INSPECT I N PHASE I x/ INAL INSPECTION <br /> INSPECTION BY DAVE 7 INSPECTION BY ted, <br /> CALL F'OR' A ,GRQUT INSPECTION;PRIOR .TOS GROU ING AND FINAL INSPECTION. , , - r. t <br /> - -- _ . _ r51731M - <br />