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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. 3? �,gj(? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued C-1 -7_I <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sart 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 /> caJ l, <br /> JOB ADDRESS/LOCATION CENSUS TRACT (2 —I- 'o-o 2- <br /> Owner's NameIto Phone l <br /> Address <br /> _ City <br /> Contractor's Name � � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Z4- <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 WellCasing <br /> Domestic/public Driven Gauge of Casing , <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. / / State Work Done <br /> ESTRUCTION 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 i �i I J"/l TITLE _ <br /> (DRAW PLOT rLAN ON REVERSE SIDE <br /> PHASE I <br /> O FOR DEPARTMENT USE ONLY <br /> J.1�x��.J 1 <br /> APPLICATION ACCEPTED BY DATE b- - <br /> ADDITIONAL COMMENTS: <br /> MERII:TGROUT <br /> �INSPECTION PHASE /FINAL INSPECTI N <br /> INSPECTION BY _ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />