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r <br /> FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT <br /> Permit No,THIS <br /> PERMIT EXPIRES 1- YEAR FROM DATE ISSUED <br /> i <br /> Application is hereby made (Complete In Triplicate) Date Issued <br /> to the' San Joaquin Local Health District fohi ' r a to' <br /> construct <br /> install the work herein described. <br /> County Ordinance No. 1862 and the"Rules andTReguapplicationths made <br /> eJin compliance <br /> ompli nCetwithnSanUJoaquin <br /> t <br /> JOB ADDRESS/LOCATIO Joaquin Loc`a1 Health District. <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> city <br /> Contractor's Name -� <br /> License # �hone� <br /> �a <br /> TYPE OF WORK (Check): NEW WELL ` <br /> / DEEPEN /__7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR / / PUMPREPLACEMENT <br /> Other /SII I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINE5 PIT PRIVY !� <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER ' po ,, <br /> INTENDED USE TYPE OF WELL ;J N <br /> Industrial I _ Cable Tool CONSTRUCTION SPECIFICATIONS <br /> /private <br /> Domestic Dia. of Well Excavation fi 1 Domestic/public Drilled Dia. of Well ng <br /> Driven Casing <br /> ji j <br /> Irrigation I� Gravel Pack Gauge of Casing <br /> Other Depth of Grout Seal <br /> 1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor d <br /> Type of Pump ;$ <br /> _ H.P. I <br /> PUMP REPLACEMENT: �I,{-_'State Work Don <br /> i�ZC.4(J <br />'VIS' REPAIR: State Work Done <br /> i� <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Materialand Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local HealthDistriet <br /> nd the State of California pertaining to or regulating well construction, Within FIFTEEN DAYS <br />€ter completion of my work on a new well, I will furnish the San Joaquin Local Hn FIFTEEN DAYS a <br /> ELL DRILLERS REPORT of the well and notify them before putting the we in use. The abov <br /> nformation is true to he best 'of my knowledge and belief, <br /> IGNED <br /> (DRAW PLOT PLAN ON REVERSETLE SIDE i} <br /> 1ASE I I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> IDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ISPECTION BY DATE <br /> INSPECTION BY DATE -..� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTINGAND FINAL INSP <br /> E H 1426 ON. <br /> 7. <br />