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SAN JOAQUIN LOCAL HEALTH DISTRICT � G! <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 <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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 6. Phone <br /> Address City <br /> Contractor's Name ; License �� ��' �6hone 6 <br /> TYPE OFWORK (Check).:. NEW WELL 'f '- DEEPEN_/?-,-RECONDITION-/7- DESTRUCTION /-7-. <br /> PUMP INSTALLATION PUMP RE AIR / / PUMP REP EMENT /-7 <br /> Other T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .,,_PIT PRIVY -. :. <br /> SEWAGE DISPOSAL FIELD 'CESSPOOL/SEEPAGE PIT OTHER <br /> j INTENDED¢USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domesti,6/private Drilled Dia, of Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> i . Irrigation Gravel Pack Depth of Grout Seal <br /> Other k Rotary - . Type of Grout <br /> Other Other Information <br /> • a f <br /> PUMP INSTALLATION: Contractor <br /># Type of Pump H.P.. �r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> t ,DESTRUCTION 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 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 _, <br /> TITLE <br /> ( W OT PLAN ON REVERSE SID , <br /> 4 <br /> FOR DEPARXMENT USE ONLY <br /> PHASE I DATE . �_�" <br /> '-A � <br /> PPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTIONP Sgmt <br /> INSPECTTION/� <br /> INSPECTION BY DATE INSPECTION BY DATE -/rte <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 7172 1M <br /> H 1426 <br />