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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 0^Z <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> This application is made in compliance with San Joaquin <br /> and/or install the work herein described. <br /> County <br /> Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION k <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address / <br /> City , <br /> Contractor's Name License # <br /> jgAZ44 Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL X/ DEEPEN /_/ RECONDITION /� DESTRUCTION / 7 x <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /? <br /> Other /-7 oP <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 Sear—"-°_ <br /> Other Rotary Type of Grout <br /> Other Other Infbrmation <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,?ESTRUCTION OF WELL: Well Diameter µ� .. " <br /> Approximate Depth <br /> Describe Material and Procedure <br /> a <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 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 I <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PEASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 9y°/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GjtOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7J72 1M <br />