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SAN JOAQUIN LOCAL HEALTH DISTRICT �_.4.4 <br /> FOR OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , � -10'0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,� -j/JL- <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 /> . , <br /> JOB ADDRESS/LOCATION '' CENSUS TRACT <br /> Owner's Name o Phone <br /> Address , City � f <br /> Contractor's Name r) Nz b4 License # ?Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEME T /� <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 a <br /> Domestic/private Drilled Dia, of Well Casing _ � <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 i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximat/epth <br /> � <br /> rib teri i nd Procedure { , �� ,Al_ r ,I hereby agree to coZe <br /> nd regulati ns o he San Joaqtiiri Local -Hedrth 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 puttin the well in e. Ahe above, + <br /> information is true to the best of my knowledge and belief. 1ld �� ,f1 fire lig f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �_J <br /> jl�PR DEPARTMENT USE ONLY <br /> PHASE I02 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROtJT , NSP CT . PHASE III/FINAL INSPECTION <br /> INSPECTION BY if DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M. <br />