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SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FOR OFFICE USE: 1601 F 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 : Rate Issued <br /> 22-1 <br /> (Complete In Triplicate) ': <br /> Application ris hereby made to" the San Joaquin Local Health District for a permit to constructs <br /> and/or install the work herein described. This application is made in compliance with San Joaquin j <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. +rA <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION d U q <br /> Phone <br /> Owner's Name <br /> city <br /> J er7`-t w <br /> Address <br /> License ��� �3 ' e <br />�_.Con.tr_attor'�s-Name, ._..� - �-�- <br /> r TYPE OF WORK (Check) : NEW WELL I DEEPEN !_I RECONDITION /_7 DESTRUCTION /? <br /> PUMP ,INSTZ ATION ./ I PUMP REPAIR PUMP REPLACEMENT /? <br /> -Other/ <br /> DISTANCE-TO NEAREST: SEPTIC. TANK _ ,SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD —_.__ CESSPOOL/SEEPAGE PIT OTHER <br /> i <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 f Driven Gauge of Casing <br /> -Irrigation Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> Other Other Information <br /> 3 <br /> s. <br /> � PUMP INSTALLATION: Contractor <br /> Type.jof.. Pump, <br /> 1 <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> ,E,22-REPAIR: , .,..._. _,_,l�� <br /> StaterWoxk.Done <br /> ,pESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> r Describe Material and Procedure <br /> s . . <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..theqbest of .my .knowledge and belief. <br /> SIGNED TITLE % Wit. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �7 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> k ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ZnEt'7 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />