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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fFOF.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I <br /> Telephone: {209} 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. 798 / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /176 <br /> 0 (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 hetLn described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a�/ i z�d the Rules and Regulations of the San Joaquin Local Health District, <br /> j i <br /> JOB ADDRESS/LOCATION r, 5 l �T � CENSUS TRACT <br /> Owner's Name Phone <br /> f <br /> k Address / city <br /> 1 <br /> r <br /> Contractor's Name ,[il'[�% License �,�,'� hn �/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/__/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP .INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 - <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANKp SEWER LINES PIT PRIVY <br /> SEWAGk DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' ! Cable Tool Dia. of Well Excavation } � W <br /> Domestic/private Drilled Dia, of Well Casing <br /> Irrigation <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: Conti ctor <br /> Type'�of Pump H.P. <br /> PUMP REPLACEMENT: /_7 �State Work Done. <br /> PUMP UPAIR: /7 ..State .Work Done { <br /> ,DFRTRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Descrabe. Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well '•construction. Within FIFTEEN DAY <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 is true to the best of my knowledge and belief. <br /> SIGNED # TITLE <br /> Ln <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> R DEPARTMENT USE ONLY <br /> PHASE I + <br /> r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br />