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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI.:OkFICE 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 <br /> A (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 ddscribed. ' 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 CENSUS TRACT <br /> Owner's Name Phone ' 3l6 <br /> Address City <br /> Contractor's Name . �._. . ..Lieense � ,. __ S-Phone== — <br /> k <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN _ RECONDITION 1 I DESTRUCTION /? <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other 17 <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 /> In atrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing k <br /> Do stic/public ! Driven Gauge of Casing + <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State..Work Done ...- <br /> 1­1_ <br /> one .LL_1 -1- State Woik�:.Done <br /> I <br /> ,DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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`wel and notify them before putting the well in use. The above <br /> information i true to the bes of my knowledge and belief. <br /> PTI { <br /> SIGNED TITLE <br /> A0 <br /> r <br /> (D LOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PaASE I <br />'a APPLICATION ACCEPTED BY `- DATE/ 7J� <br /> ADDITIONAL COMMENTS <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. .G� DATE <br /> r ' <br /> .. CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> V u 1A9A 5/731X <br />