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SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT <br /> .,j,0i OFFICE USE: 1601 E. Hazelton"•Ave. ,.-Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit No. 3L 4/ <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date .Issued <br /> (complete In Triplicate) Cr r-j'o <br /> Application is hereby made to the San Joaquin Local Health District for a peri to construct <br /> and/or install the work herein described. This application -is made in compiiaace �;ith' San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations- of, the Sari°Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONAlCENSUS TRACT e` <br /> Owner's Name <br /> _ Phone d;Q <br /> Address <br /> - --~�- Cit 0 - <br /> Contractor's Name <br /> License # a t Phone <br /> TYPE OF WORK (Check) : NEW WELL g/ DEEPEN /_� RECONDITION /-7 DESTRUCTION /7. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 -- <br /> { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> 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 � X, ; <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done <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 TITLE 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FO ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY —' DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION _ PHAS <br /> A IJI/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N_. <br /> E H 1426 7/72 1M�01 w <br />