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SAN J UIT LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 tjie Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONL �" AIL&ICENSUS TRACT <br /> d <br /> Owner's Name o->i 103a dV 0d-,' Phone <br /> Address _����'J._��1 rw 0-4,Gr City �,.v _. <br /> S"?t S 4/0-0 <br /> Contractor's Name License # 2(27 Phone'7— <br /> Phone Qg,f -7;2[1_ <br /> l <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <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 /> Domestic/private Drilled Dia. of Well Casing 16'(1 ,,/ <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal Sa f ^ <br /> Other Rotary Type of Grout �a <br /> Other Other Information <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 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 w TITLE <br /> E0 V (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' JIIJFINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,�� DATE Y-j - ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINALt-,INSPECTION. <br /> E 1426 ;p . 7/72 1M <br />