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P. <br /> 'FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. � <br /> THIS PERMIT. MIRES 1 YEAR FROM DATE ISSUED <br /> A (Complete In Triplicate) Date Issued <br /> Application fs'hereby made to �the San Joaqu _A/ <br /> in Local Health District for a permit to con <br /> and/or install the work herein described. This application is made in compliance <br /> (County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin construct <br /> tP with San Jaaquirf <br /> q n Local Health District. <br /> JOB ADDRESS/LOCATION <br /> f CENSUS TRACT <br /> � Owner'st�Name <br /> t 2rn <br /> Address q 1A <br /> Phone <br /> City <br />' Contractor's Name . <br /> a <br /> License # /060 Phone - + <br /> TYPE OF WORK (Check) . NEWWELL`/ DPENY _ + <br /> _/�'"'�RECONDITION %_7—DESTRUCTI-ON'"/7- <br /> PUMP INSTALLATION L/ PUMP REPAIR _/ / PUMP REPLACEMENT /? <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _,2)�_ SEWER LINES X1`` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD va <br /> CESSPOOL/SEEPAGE PIT _ OTHER <br /> ' o <br /> INTENDED USE <br /> i� TYPE Of WELL RUCTION SPECIFICATIONS <br /> . LL Industrial CONSTLACable Tool, <br /> Domestic/private ii Drilled Dia. of Well CExcavati <br /> asing <br /> on y <br /> Domestic/public Dia. of Well Casing <br /> Irrigation — —� Driven Gauge of Casing <br /> Other �, Gravel Pack ' Depth of Grout Seal `�--- <br /> C­� Rotary ,Type of Grout <br /> Other ' Other Information a <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> -is H.P. <br /> PUMP REPLACEMENT: / '/ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL° W 11Dia at"er'� <br /> Describe Material and Procedure APProximate"Dept - = <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri <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 <br /> information s true to the best of my knowledge and belief, <br /> SIGNED ` <br /> TITLE <br />- (DRAW PLOT PLAN ON REVERSE SIDE <br />'HASE I OR EPARTMENT SE ONLY <br /> FPLICATION ACCEPTED BY <br /> iDDITIONAL COMMENTS: ? DATE <br /> PHAS II G UT IN ECTION / <br />;NSPECTION BY ATEPHASE FINAL INSPECTIO <br /> �— INSPECTION BY DATE ,. <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 <br /> 7/72 1M Gi <br />