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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: 1P'(209) '466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES, I YEAR FROM DATE ISSUED Date Issued7S <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q CENSUS TRACT <br /> Owners Name Phone 3 _3l qj <br /> ddress 5 City <br /> 'Contractor's Name License # E����( Phone d^�/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�/ RECONDITION / / DESTRUCTION /—T <br /> PUMP INSTALLATION _Al::/ ' PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / U <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 Casi.,-�g <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grgbt , <br /> Other Other Information <br /> PUMP INSTALLATION: Contractors -<<x��' <br /> Type of Pump �- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 construG,f n. 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 we 1 in use. The above <br /> information is true to the best of my knowledge and belief. p� <br /> SIGNED ( '�'� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTION PHA. E i FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE —I <br /> CALL FOR A G INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br /> E H 1426 7/72 IM <br />