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SAN JOAQUIN LOCAL HEALTH DISTRICT IP <br /> POT', OFFICE USE:: 1601 E. Hazelton Ave, <br /> , 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 ��7� <br /> ,�,�`,�; - ete 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> ,TOB ADDRESS/I.00ATIQN - p'e . � � CENSUS TRACT <br /> Owner's Name <br /> l/U /NG e /1Phone X 7 <br /> City <br /> Address <br /> Contractor's Name �"! <br /> J License Phone �� <br /> TYPE OF.WORK (Check): NEW WELL DEEPEN / RECONDITION_/ / DESTRUCTION /? <br /> PUMP INSTALLATI `MP REPAIR / I PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA;4K SEWER LINES PIT PRIVY •" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE,,OF WELL CONSTRUCTION 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 <br /> Other Other Information •" <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump 4;L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> DFfiTRUCTION 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 DRI REPORT of the well and notify them before putting the well in use. The above <br /> informat n is rue to the best of my knowledge and belief. <br /> � SIGNED <br /> �- TITLE Z614re-�� <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATEC4" <br /> APPLICATION ACCEPTED BY c <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATEINSPECTION BY-- DATE <br /> CALL FOR A �OUTINSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br /> E H 1426 <br />