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IC <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'0£.:,OFF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-�{75�U <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 the Rules and Regulations of tl San Joaquin. Local Health District. <br /> JOB AADRESS/LOCATION _ NSUS TRACT ' <br /> Owner's Name 1!F Phone <br /> Address City <br /> Contractor's Name 1 License # Phone <br /> a - <br /> TYPE OF WORK (Check): NEW WELL /P DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other -/ / <br /> a o. <br /> f � <br /> DISTANCE TO NEAREST: SEPTICITANK cr-0/ SEWER LINES PIT PRIVY <br /> SEWAGErDISPflSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> .-. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Af <br /> Domestic/private :Drilled Dia. of Weil Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary Type of Grout <br /> I Other Other Information ' �. <br /> PUMP INSTALLATION. Contrlctor <br /> Type of Pump N, H.P. - <br /> PUMP <br /> .P. -PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> .DR-,TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of theiiksan Joaquin Local Health District <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS s <br /> after completion of my work on a new well, I will .furnish the S' an Joaquin Local Health District a <br /> b <br /> WELL DRILLERS REPORT of the well and notify them efore putting the well, in use. The above <br /> information is true to the best of, my knowledge and belief. M <br /> SIGNED <br /> TITLE <br /> (D T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY � R � � DATE �!� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE - zg'�+� _ INSPECTION BY /,,�.4� DATE <br /> CALL-FOR sA GROUT -INSPECTION •PRIOR TO GROUTIV, 4rFINAL INSPECTION. u <br /> mo <br /> E H 142b <br />