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- / SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> OFFICE USE: l/ .1601 E. Razelton Ave. , Stockton, Calif. 75-, 430"�. <br /> ----- Telephone: (209) 466-6781p i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zz <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> Date Issued f <br /> (Complete In Triplicate) <br /> 1 Health District <br /> ra permit t <br /> Application is hereby made to the SanJoauin Lsoapca plication ismade incompliancewi.thnct Sa�nuJoaquin <br /> and/or install the work herein described. * <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT " <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name ' f <br /> City <br /> Address } <br /> 3'"'r <br /> Licenseehone <br /> Contractor's Name <br /> 1 <br /> _-.. _ <br /> STRUCTION <br /> TYPE OF WORK (Check) : NEW WELL " DEEPEN / UAIRRECON �IN/I PUMPEREPLACEMENT�I� <br /> PUMP INSTALLATIO I I <br /> Other ./ / <br /> PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT <br /> FIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> TYPE WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of We11 Excavation <br /> Industrial _ _ Cable Tool <br /> yDomestic./private Drilled Dia. of We11 Casing \ <br /> �-r`h { Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Other . Rotary Type of Grout R <br /> Other Other Information" <br /> 1 PUMP INSTALLATION: Contractor H.P. <br /> I Type of Pump <br /> PUMP REPLACEMENT: /J' State Work Dome <br /> . <br /> .PUMP <br /> _REPAIR•,; . . - :=-/ StateWar-k=done <br /> Approximate Depth <br /> DFI-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> well 'construction. Within FIFTEEN DAYS <br /> i snd the State of California pertaining to or regulating <br /> Iwill <br /> after completion of my work on a new notifthembefaresputtingaJoaquin Local <br /> the well inuse.HeTheh boverict <br /> i WELL DRILLERS REPORT of the well and y <br /> information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED ��� <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY n <br /> PHASE I �� ��� C/t. DATE <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COi,0iENTS <br /> PPHASE III/F NAL INSPECTION <br /> PHASE II GROUT- INSPECTION <br /> INSPECTION BY DATE INSPECTION BY' , <br /> DATE" Lz- 1�-,7� <br /> CALL FOR A GRTNSPECZOi 0 GRI7UTING AND FINAL INSPECTION. ,/ <br /> _ <br /> 4 F, x 1426 - <br />