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VVV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE, USE: 1.601 E. Hazp1ton}Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 g <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y <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 /> 3-574 . <br /> JOB ADDRESS/LOCATIONCENSUS TRACT " <br /> i ^A1,0 06�:6 T <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN '/% RECONDITION I / DESTRUCTION / <br /> PUMP INSTALLATION / / 1'L"ML' REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casings -__- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout ,A/L1V4 <br /> 7f Other Other Information " y = <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _/ / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done l <br /> .DFgTRUCTION 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 i ,e to a bes f my knowledge and belief./;/V Webs' ,6aF��, 1l <br /> SIGNED TITLE �7- 46;--f7t�, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,/� <br /> APPLICATION ACCEPTED BY ��D' ATE' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II FW INSPECTI <br /> INSPECTION BY DATE INSPECTION ATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - _E H 1426 — - - -5/73 art-- <br />