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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US ': -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 /> 1 (Comple'te' ln 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 As made in compliance with San Joaquin <br /> County Ordinancce69Noo..,,1862 and the Rules and Reg lations of the San Joaquin Local Health District. <br /> 12 <br /> JOB ADDRESS/LOCATION CC CENSUS TRACT f <br /> Owner's :Name er r �� y' 7hone , <br /> Address I!d 'f � . . /J�-c d� a� City' ' <br /> Contractor's Name a-157 _je- License Ga j3_�P- Phone ;3_4iV/,, <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION A;�I_ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <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 Seal <br /> Other Rotary Type of Grout q <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <br /> PUMP REPLACEMENT: State Work Done 6-,�• � <br /> PUMP REPAIR: / / State Work Done <br /> i <br /> ,DESTRUCTION 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 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 is true to the best of my knowledge and belief. ° <br /> SIGNED C - TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY C/ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION I <br /> INSPECTION BY DATE INSPECTION BY DATE��/� �r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H,i42b - _ 4/72 1M <br /> 1� <br />