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FOR OFg SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FICE USE:. 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> e�,, Telephone: (209) 466-6781 <br /> ° ,PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- s <br /> THIS PERMIT EXPIRES. I YEAR FROM DATE ISSUED <br /> • Date Issued <br /> APPlication is herebymadeto •the San (JaaquineLocal Health District foraermit t , <br /> and/or install the work herein described. This application is made in compliance with San Joaquin, <br /> A o construct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . <br /> Owner's Name CENSUS TRACT - -- f <br /> t <br /> Phone <br /> Address 1` <br /> City <br /> Contractor's Name <br /> License # Phone f <br /> TYPE OF WORK (Check): NEW WELL /X7 DEEPEN <br /> �' / RECONDITION'/� DESTRUCTION /_7PUMP INSTALLA TION PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> INTENDED USE TYPE OF WELL CE5SP04L/SEEPAGE. PIT OTHER <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> 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 /> 31 <br />� - Other Rotary Type of Grout � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor A <br /> Type of Pump <br /> H.11. <br /> PUMP REPLACEMENT: <br /> X/ State Work Done <br />'UMP REPAIR: / / State Work Done` E <br />)ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind .the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. <br /> IGNED <br /> TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II FINAL�DATE <br /> ECTION <br />!JSPECTION BY DATE _ INSPECTION EY <br /> e <br /> CALL„F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />