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t . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 161 t. Hazelton Ave, , Stockton, Calif. <br /> } � on <br /> Tele he: <br /> -'' P � (209) 456-5781 <br /> i. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;�,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - , _��� <br /> I IT DateX�sued/,2 / <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to . Qnstru <br /> and/or install the work herein described. This application is made. in compliance with'Sa ct <br /> County Ordinance No. 1862 and the Joaquin <br /> Ru es and Re ulatio s o he San Jo quin Local Healh,District ' <br /> Cleo <br /> JOB g/LO TON s•, �: . <br /> CENSUS TRACT <br /> Owner's Name E <br /> Phone <br /> I Address � <br /> City <br /> Contractor's Name, yr t110 <br /> T� <br /> :::1111 Jill <br /> 9 License && Phone <br /> TYKE OF WORK (Check): NEW- WELL � DEEPEN /;„ RECONDITION /_7 DESTRUCTION /_7 <br /> _ I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-/ --- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELDPIT PRIVY <br /> �"QQCESSPOOL/SEEPAGE PI /�//� OTHER <br /> INTENDED USE <br /> TYPE OF WELL <br /> Industrial _ CONSTRUCTION SPECIFICATIONS <br /> Cab Tool Dia, of Well Excavation <br /> Domestic/private Drilled6 <br /> Domestic/public Driven Dia. of Well Casing Z_ <br /> Irrigation Gauge of Casing <br /> Gravel PackDepth of Grout Seal ► � <br /> Other Rotary �- <br /> -Type of Grout �- E <br /> Other Other Information <br /> PUMP INSTALLATION.- Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / J State Work Done <br /> H.P. ./ <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well--,Diameter.. . <br /> Describe Material and Procedure Approximate Depth <br /> i <br /> I hereby agree to comply withfall 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 'Ili new we`ll, I will furnish the San Joaquin Local'Heaith 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ---- <br /> PHASE I FOR DEPARTMENT USE ONLY <br />,PPLICATION ACCEPTED BY DATE �� G <br /> WDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL <br /> INSPECTION BY DATE INSPECTION BY INSPECTION <br /> ATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />