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SAN JOAQUIN LOCAL HEALTH DISTRIFM <br /> FOR OFFICE USE: 1(7-) E. Hazelton Ave. , Stockton, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE Permit No. ;�j•- / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a, = ed /7'7 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �+Wc r CENSUS TRACT Cu <br /> Lr <br /> Owner's NameR <br /> Phone <br /> F <br /> AddressCity �^ <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : ' NEW WELL / / DEEPEN /% RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION bCT PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WHLIVCONSTRUCTION SPECIFICATIONS <br /> Industrial 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 /> Other Rotary Type of Grout a <br /> Other Other Information <br /> PUMP. INSTALLATION: Contractor ile-l", <br /> Type of Pump 7 , H.P. <br /> PUMP REPLACEMENT: State' Work Done c ` "�J la Jsi / <br /> PUMP REPAIR: /% State Work Done P <br /> Cud P <br /> oZ id. N <br /> DESTRUCTION 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 ` TITLES <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4AC 1_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE - '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 72 1M <br />