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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0111 " 'ICE <br /> USE: � 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> ;' Telephone: (204) 466 -6782 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> Date Issued <br /> ii (Complete In Triplicate) <br /> Joaquin Local <br /> District ra permit t <br /> Application is hereby i-nade to the <br /> hesSan ed. - This application is made incompliancewithnSanuct Joaquin <br /> and/or install the work herein <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the <br /> " CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> :, � Phone <br /> Owner's Name 114 oll <br /> i <br /> City Address . T <br /> c� �6�� <br /> i License # Phone, <br /> Contractor's Name . .. <br /> TYPE OF WORK (Check <br /> ) : q NEW WELL/ / DEEPEN 7 <br /> / / RECONDITION 1�1I DESTRUCTION /�T <br /> PUMP INSTALLATION / / PL`MP REPAIR PUMP REPLACEMENT I <br /> Other / I <br /> DISTANCE TO. NEAREST: ,SEPTIC TANK SEWER LINES PIT PRIVY <br /> ':. SEWAGE DISPOS L FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, o€ Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ! <br /> Domestic/public'� Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> iOther Other <br /> i Other Information <br /> l <br /> i <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 'REPAIR: State Work Done' <br /> - <br /> Approximate Depth <br /> DF-,TRUCTION OF WELL: ! Well Diameter pP G <br /> Describe Material and Procedu e <br /> lewith all Laws and regulations of the San Joaquin Local. Health District <br /> I hereby agree to coznpl.y <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 DRILLERS REPORT of .the well and notify them before putting the wel use. The above <br /> k information is to the best of m knowledge and belief. <br /> i TITLE <br /> ;i SIGNED <br /> i a (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I �� DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE 111/FINAL INSPECTIO <br /> PHASE TI GROUT INSPECTION INSPECTION BY DATE a O <br /> INSPECTION BY DATE <br /> .,CALL FOR A GROUT;i-INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. 5/731X <br /> V U IL9A Y <br />