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14 SAN J'OAQUIN LOCAL HEALTH DISTRICT {# <br /> FOF.':-017FII_E USE: 1601 E. Hazelton Ave. , Stockton,Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUN .'APERMIT Permit No;. _ss":3� <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE 'ISSUED? Date Issued _ -,j� <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 Sant Joaquin <br /> County Ordinance No: 1862 andsthe Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> .TOB ADDRESS/LOCATION1 ,f CENSUS TRACT S � <br /> - Phone <br /> Owner`s Name <br /> Address - City " G <br /> License # Phone <br /> Contractor's Name ' <br /> I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> PUMP INST LATION / / PL`MP REPAIR/ / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .0_ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �V <br /> INTENDED USE TYPF, OF WELL CONSTRUCTION SPECIFICATIONS (� , <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private .!- Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other Other Information ' <br /> PUTT INSTALLATION; Contractor <br /> Type'of Pump H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> _ 1 <br /> PUMP T2EPAIR: / .State-Work.Done <br /> ,IIFsTRUCTION 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 Ca"lifornia-1pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> aftercnm ion of my worklon a new well, I will furnish the San Joaquin Local Health District a <br /> ZdEZL Doom ER REPORT of' thejwell and notify them before putting the well in use. The above <br /> Lnforma>tii t the best of my knowledge and belief. TITLE <br /> k I , (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> P14ASE I <br /> APPZICATION ACCEPTED BY.`L DATE <br /> ADDITIONAL COMMENTS: <br /> . PHASE I GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> CALL- FOR A•GROUT- INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> 5/731Nt <br /> V Tj I A I A � <br />