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�..� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave,' ; Stockton, Calif. ' <br /> Telephone: , (209) 466-6781 <br /> No. <br /> APPLICATION FOR WELL CONSTRUCTIONOR PUNT' PERMIT Permit <br /> t <br /> THIS PERMIT EXPIRES l 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 /> f F r CENSUS' -TRACT :a <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name,. <br /> . .City <br /> Address <br /> r a <br /> l %/L 1 ,,!! <br /> ? ��77Phone�,���T'� <br /> Contractor's Name License �� . . . <br />} TYPE OF WORK (Check) : NEW WELL ts, DEEPEN/ / RECONDITION /7 DESTRUCTION -7 <br /> PUMP INSTALLATION/ I PUMP REPAIR'/ <br /> / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE rTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private :trilled <br /> Dia. of Well Casing <br /> — <br /> Domestic/public <br /> ublic Driven Gauge of Casing / <br /> Irrigationr = --Gravel Pack Depth of Grout SeaCPOl <br /> Rotax Type of Grout <br /> Other k —. Othery, Other Information <br /> �---— <br /> k <br /> r PUMP INSTALLATION: Contractor H.P. <br /> Type of-Pump <br /> . PUMP REPLACEMENT: / / State Work Done -�l } <br /> i <br /> P PAIR• /_I State .Work-.Donee._ -- - -- --. ._ <br /> —- �. � _- =r T <br /> _DESTRUCTION OF WELL: Well Diameter— <br /> Approximate-r- - <br /> Approximate Depthcro <br /> ` _ <br /> E Describe Material and Procedure <br /> ' <br /> I hereby agree to comply ywith 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 <br /> before <br /> fbelieft�ng the well in use. The above <br /> information is true to the bestand <br /> N of my knowledge _ M <br /> i <br /> TITLE <br /> SIGNED - <br /> # sem_ 4. n <br /> (DRAW PLOT PLAN 'ON +REVERSE SIDE) r <br /> FOR.DEPARTMENT USE ONLY ' <br /> PHASE I ' DATE .� <br /> APPLICATION- ACCEPTED BY <br /> ADDITIONAL'iCOMMENTS: P}•TASE III/FINAL INSPECTION <br /> f PHASE II GROtT INSPECTION " > DATE ,3"=/✓'lG- <br /> INSPECTION BY I DATE <br /> -INSPECTION BY <br /> CALL F0IR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 . <br /> k - <br />