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R SAN JOAQUIN LOCAL HEALTH DISTRICT ��J <br /> F OFFICE USE: 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San 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 /> l County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3190 ,91 . CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City <br /> Contractor's Name T License WC 2,373 Phone3!� <br /> TYPE OF WORK (Check): NEW.WELL I I DEEPEN /-7 RECONDITION /-7 <br /> DESTRUCTION /-7PUMP INSTALLATION / PUMP REPAIR,-fPUMP REPLACEMENT /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> TYPE OF WELL �P <br /> INTENDED USE CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven <br /> 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 <br /> H.P. . S~- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR* f ` State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> � Describe Material and Procedure 'Approximate Depth-- - - - . <br /> r <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 <br /> and belief. <br /> SIGNED -Z-cO TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) -- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -e4 ! DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 4' -- <br /> INSPECTION BY � DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />