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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —r-O-F. O1,FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ._ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S4 <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 /> 1 and/or :install the work herein described. , This application is wade in compliance with San Joaquin <br /> 1` County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> I JOB ADDRESS/LOCATION CENSUS TRACT <br /> f f <br /> Owner's Name Phone <br /> r <br /> Address City <br /> Contractor's Name ?, License #/ ZA j Phonev� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/-7 RECONDITION /_/ DESTRUCTION F7 <br /> PUMP INS AL TION /% P�, REPAIR /—/ PUMP REPLACEMENT /7 <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 <br /> d Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t-•Gravel Pack Depth of Grout Seal <br /> Other __ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP RfEPAIR: / / 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 /> 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 /> /714 Zxim <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> — <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE I SP CTION BY DATE <br /> CALL FOR A GROUT SPECT� PRIOR 0 GROUTING 1�FINAL INSPECTION. <br /> E H 1•426 5/731M <br /> A <br />