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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OtrFICE 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) 3 <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 /> JOB ADDRESS/LOCATION Jb <br /> SUS TRACT <br /> Owner's Name + <br /> Phone <br /> Address <br /> City <br /> Contractor's Name �� License #/At7�phone 4�Eb <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE 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 /> A <br /> PUMP INSTALLATION: <br /> Contractor �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <br />$ESTRUCTION 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 lltrue to the best of my knowle a ani elief. <br /> SIGNED�✓� ITLE3wLMM <br /> PLOT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 3 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE JII FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE(ITIW. <br /> E H 1426 7/72 1M <br />