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�y � 6/ 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 2-� <br /> .2:;f� (Complete In Triplicate) '255- 2-70 --D.6 <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 Joaqui.tn <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health 'Distri<ct. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name a= Phone <br /> Address City ' <br /> Contractor's Name License Phone .75 <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Q <br /> Other l / <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 <br /> Domestic/public Driven Gauge of Casing <br /> 14k Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work 'Done <br /> t <br />:i PUMP 'tEPAIR: / / State'Wo'rk Done <br /> � �__.. Approximate Depth <br /> DFRTRUCTION OF WELL: Well Diameter _ pP <br />' Describe Material and Procedure <br /> i{ I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> E'. 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 /> I! 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 ll,- --,1- ,�nA�_ <br /> (DRAW PL PLAN ON REVERSE SIDEr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t r G�C� <br /> APPLICATION ACCEPTED ,BX DATE <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTIONPHASE 141/FINAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> - - ,... �73llK . <br />