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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_17;?rrj_R, 0��ICE 'Zsx: 1601 E. Hazelton,Avo. , _-Stockton, Calif. <br /> W Telephone: ' x(209) -4666781 <br /> APPLICATION FOR WELL CONStRUCTION,fOR'PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES- I ,YEAR, FROX DAT Z 1 S SUED., Date -Issued <br /> 1. (Complete In.Triplicate). <br /> Application I is.-hereby-made.-,.to! the San .-,Joaqijin. .Local Health Districtsfor-a.-permit to. construct <br /> and/or install the work hereindescribed. Thisapplication.,,is :.made, in compliance with San Joaquin <br /> County .Ordinaace.No.-,1862,.,andir. he.,Rules-F,and -Re cal 'Health District. <br /> gulations ,of ,,the' San Joaquin-Lo <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION L�4 &A—I&I -- <br /> J ILI <br /> 41- <br /> owner's Ndmd' -P hone <br /> Address 2 6?=I-P7 ,g2 City. <br /> t7 <br /> X n <br /> cese 77� LPhone 3 41J <br /> Contractor's^ <br /> Name LiIt I <br /> ► 512 _S641 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION -/ PUMP REPAIR '/ PUMP REPLACEMENT 17 <br /> Other -1 <br /> DISTANCE TO NEAREST: SEPTIC TANK S-Dp SEWER LINES Sea PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S-oo CESSPOOL/SEEPAGE PIT G pp OTHER <br /> INTENDED USE TOE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing — 12 <br /> ,V Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> I Other Other Inforrhation '-- <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> Approximate Depth <br /> .DESTRUCTION OF WELL: Well Diameter <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, .1 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 the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE BY DATE <br /> CALL_. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' 4/72 1M- 1 <br />