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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. ,lam: 4�y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> (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 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 ADDRESSIL0CATION `T e CENSUS TRACT <br /> Owner's Name ? �� <br /> - '-2� Phone3 9f-11 <br /> Address `� �` n� l <br /> City � �2 <br /> Contractor's Name License d��z�91v0 Phone 727-JTYe <br /> TYPE OF WORK (Check): NEW WELL /_7DEEPEN /"7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <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 p , <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 � I <br /> Other Rotary _TYPe" 'of,Grout <br /> Other Other Information <br /> o F4- 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: StS t © ` <br /> ate Work Done <br /> PUMP REPAIR: / / State Work Done <br /> I <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> FK <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 DRIL-LERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true-to the best of- my. kinowledge and belief. <br /> SIGNED / <br /> TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTION BY a DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426f 7/72 1M <br />