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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75=f 3t�lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 11 (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 Sart Joaquin <br /> County Ordinance No. 1562 and the Rules and Regulations of the Sart Joaquin Local Realth District. <br /> JOB ADDRESS/LOCATION E CENSUS TRACT - <br /> Owner's Name Phone <br /> Address �` City <br /> Contractor's Name License I�jl�Jj� Phone 3 � J3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/_/ RECONDITION f_1 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <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 neva well, I will furnish the San Joaquin Local Health District a <br /> 14ELL 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 /> G <br /> SIGNED7 <br /> (DRAW PLOT PLAN ON REVERSETSIDE)� - <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE j'� " <br /> ADDITIONAL COMMENTS: <br /> I GROUT INSPECTION P S I FINAL INSPECT ON <br /> INSPECTION BY DATE �'1 JiINSPECTION BY DATECALL FOR ATSE <br /> OUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br />-- E H 1426 5/731M <br />