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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> 77 Telephone: . (209) .466-6781 <br /> J <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> tf . a <br /> T S PERMIT -EXPIRES 1:. YEAR FROM DATE 'ISSUED Date 'Issued 7-7v <br /> (Comple.te In Triplicate) <br /> Application is hey 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. 1$62 and the Rules. and Regulations of the San Joaquin 'Local Health District. <br /> ji <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION �/ 3 11/ � � <br /> .._ <br /> i <br /> Owner's Name a r►n!1n ie Phone <br /> Address City <br /> Contractor's Name <br /> License # Phone <br /> k <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / — y <br /> r � <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 II Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing y <br /> Domestic/public Driven Gauge of Casing n <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ! Contractor ' ; <br /> i Type of Pump ,.-s H.P. ! <br /> I <br /> PUMP REPLACEMENT: ! State Work Done +Cr? E <br /> PUMP REPAIR: II <br /> /7 State Work Done <br /> .i <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I`. 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 t-.em before putting the well in use. The above <br /> information is true to the bes my, nowledge nd belief. <br /> SIGNE TLEO" ". <br /> (DRAW PLOT PLAN 014' RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY VU - K� ATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION B D <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I PCT <br /> E H 1426 04/72 IM <br />