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1 / SAN JOAQUIN 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 No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to)ithe '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 /> JOB ADDRESS/LOCATION ` E,NSUS' TRACT <br /> Owner's 'Name Phone <br /> Address City`- <br /> Contractor's <br /> ity`Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL /r�DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /�tJMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / J <br /> DISTANCE T0. NEAREST: SEPTIC TANK , rj ./SEWER LINES [ IT PRIVY' j � <br /> SE{iAGE DISPOSAL FIELD � �--CESSPOOL/SEEPAGE ..PITAK�..!A-,_Q ----y I <br /> kn. i �--.-tet <br /> r <br /> N ) <br /> INTENDED USE ,> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .,Industrial Cable Tool` Dia. of Well Excavation <br /> omestic/private Drilled F Dia. of Well Casing _ <br /> ' Domestic/public Driven' Gauge of Casing ;2z G} <br /> Irrigation Gravel Pack Depth of Grout 1 S` 02 \Q` <br /> Other Mary Type of Grout <br /> Other Other Inforimation "`, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> t <br /> PUMP REPAIR: / /State Work Done " <br />.DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> I hereby agree to cdmply with all laws ,and regulations of the San Joaquin Local Health District <br /> and the State of California pe.rtaining' 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 puttingf,the well in use. The above <br /> in ation is true to o knowledge and belief. <br /> SIGNED TITLE <br /> PLOT P ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTS W� Y i l _ DATE rj I U 1 <br /> ADDITIONAL CO <br /> r <br /> P I G UT INSPEtTn <br /> PHASE III/FINAi, INSPECTION <br /> INSPE DATE �` r INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRO OUTING AND FINAL INSPECTION. <br /> E H 1426. ,� {.' -7/72 1M <br />