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.T? SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> PEO-F: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 <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 Health District. � <br /> J ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address City <br /> Contractor's Namea4 Ea <br /> - License # PhoneiD' / <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN '/—/ RECONDITION /_% DESTRUCTION /`7 <br /> PUMP INSTALLATION / / Pt,'I4fP REPAIR / / PUMP REPLACEMENT /-7 1" <br /> Other . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 57 <br /> 'r _ �c?ate i <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 /> Domestic/public Driven Gauge of Casing - -- . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout ®l f' <br /> Other Other Information yam ;; <br /> PUMP INSTALLATION: Contractor <br /> _ Type of Pump H.P. �. <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ 7 `1 <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFCTRUCTION 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 /> [,SELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatio rue to the 'best of my knowledge and belief.Wd <br /> SIGNERA 777 TITLE .`- . ?tea <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 II QRQUT INSPECTION PHASE I INA <br /> JL INSPECTION <br /> INSPECTION BY DATE - -- INSPECTION BY ZADATE Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />—_._E R 1426 — [�/71 Y u <br />