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SAN JOAQUIN LOCAL UALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. 73 -dy e Y " <br /> -Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERFSIT Permit No.- - <br /> THIS PERMIT 'EXPIRES 1 YEAR FROMr DATE ISSUED , Date Issued <br /> i (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 /> es and Regulations of the San Joaquin Local Health District, <br /> County Ordinance No. 1862 and ,the Rul <br /> JOB ADDRESS/LOCATION <br /> r CENSUS TRACT <br /> * Phone 31 r <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's Name License jd0V7f� Phone <br /> TYPE OF WORK (Check) : NEW WELL -/, DEEPEN/ / RECONDITION /� DESTRUCTION /? - - <br /> - PUMP INSTALLATION L PUMP REPAIR' / PUMP REPLACEMENT / <br /> Other <br /> —0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 'r <br /> SEWAGE DISP SAL FIELD �/�- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> strial Cable Tool Dia. of Well Excavation a`L Oe <br /> indu Pr- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 4.10.0 <br /> Irrigation Gravel Pack Depth of Grout Seal _ r O <br /> Other Rotary Type of Grout _ /lge- _ r _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor A OP-s <br /> Type of"'Pump <br /> PUMP REPLACEMENT: / / State'Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> and regulations of the San Joaquin Local Health District, <br /> I hereby agree to comply with all Laws <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 0, the well and notify thein before putting the well in use. The above <br /> information is tr to he of my knowledge and belief. <br /> SIGNED TITLED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> h PHASE I DATE 2� <br /> APPLICATION ACCEPTED !BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHASE /FINAL INSPECTIO <br /> INSPECTION $Y DATE INSPECTION BY DATE <br /> CALL FOR A OUT INSPECTION PRIG TO GROUTING AND FINAL ,INSPECTION. 4/72 1M <br /> E H 1426 <br />