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FOR QFFICE E; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone: (209)' 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNK' PERMIT Permit No. <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED <br /> , (Complete In Triplicate) Date Iasued(_ _ � <br /> Application is hereby made to the San Joaquin LocalHealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> -JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> ` Phone � <br /> Address t <br /> City <br /> Contractor's Name <br /> License # 4 937,3 Phone `' M <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN _ <br /> _/-7 RECONDITION /-7DESTRUCTION /-7PUMP INSTALLATION —/ / PUMP REPAIR / / PUMP REPLACEMENT / 1 <br /> Other -- <br /> DISTANCE TO NEAREST; SEPTIC TANKk <br /> SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Domestic <br /> �— Cable Tool Dia. of Well Excavation <br /> _ Domestic/Private Drilled Dia. of Well Casing J <br /> Domestic/public Driven Gauge of Casing <br /> �- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 'ry <br /> Other Other Information <br /> PUMP INSTALLATION: • <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ,� <br /> !�� State Work Done <br /> PUMP-REPAIR: E / / -State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Describe Material and Procedure Approximate Depth <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> snd 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 /> SELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />-nformation is true to the best of my knowledge and belief. <br /> SIGNED . <br /> TITLE <br /> (DRAW PLOT' AN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY / <br /> DDITIONAL COMMENTS: DATE 6- - <br /> PHASE I GROUT INSPECTION PHASE II FINAL INSPECTTQN <br /> NSPECI�ION BY DATE INSPECTION $Y <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 <br /> - 7/72 1M 46L'' <br />