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FOR.OFFICE USE: <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601. E. Hazelton Ave., Stockton, Calif.. <br />Telephone: (209) 466-6781 . <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;�// <br />THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued Za <br />(Complete In Triplicate) <br />Application is hereby made tolthe San Joaquin Local health District for a permit to construct t <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 ADDRESS/'L0CATIO �. £ <br />Os. <br />CENSUS TRACT <br />Owner's Name { <br />�; Phone - (, r <br />Address 9 �. t y <br />City I <br />Contractor's Name <br />License # Phone � <br />h <br />TYPE OF WORK (Check): NEW WELL / / DEEPEN / % RECONDITION /_7 DESTRUCTION / <br />PUMP INSTALLATION./ / PUMP REPAIR / / PUMA' REPLACEMENT /_7 � <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 I Cable Tool Dia. of Well Excavation <br />iQ Domestic/private I Drilled Dia„ of Well Casing <br />Domestic/public `t Driven Gauge of Casing <br />Irrigation .1 Gravel Pack Depth of Grout Seal <br />Other I Rotary Type of Grout <br />I Other Other Information <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />Contractor <br />Type of Pump <br />State Work Done ....�,.- <br />H.P. <br />PUMP REPAIR. / / State Work Done T <br />RESTRUCTION OF WELL:. Well Diameter <br />•• Approximate Depth <br />Describe Material and .Procedure <br />I hereby agree to comply with `a11.,Iaws-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 <br />WELL R RS RE RT o the well and notify them before putting the well in use. The above <br />information is true o t e best of my knowledge and belief. <br />SIGNED <br />TITLE _ <br />(DRAW PLOT PLAN ON REVERSE SIDE)` <br />L � rc��t DEQ <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />[NSPECTION BY DATE INSPECTION BY <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br />USE ONLY <br />a <br />DATE <br />- 1 <br />INSPEC <br />DATE <br />E H 1426 ----__.. <br />i 7/72 IM <br />