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4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUE70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7,6--g,g/1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> s County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> f JOB ADDRESS/LOCATION ` CENSUS TRACT <br /> i. Owner's Name Phone , Z.Z, i <br /> Address <br /> City <br /> � �, <br /> Contractor's Name .Dicense �u Phoned?W;Z <br /> TYPE OF WORK (Check) : NEW. WELL /Z7—DEEPEN �/7 (RECONDITION /-7 DESTRUCTION /7 <br /> f PUMP INSTALLATION "/L��UNP REPAIR'/-7 PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES PIT PRIVY <br /> i d SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'*PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL � <br /> j INTENDED USE 'c, ,TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial ,��!- ']e Tool Dia. of Well Excavation ZX CN. <br /> 1 <br /> testic/private Drilled Dia. of Well Casing X <br /> Dotitestic/public .. t Driven' Gauge of Casing <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other. Other Information <br /> t Geophysical 'k 1 Surface Seal Installed BY: <br /> } PUMP INSTALLATION:} Contr'actof <br /> ".T —Type-.of' Pump H.P. <br /> PUMP REPLACEMENT: 1 / / State Work Done � r ' <br /> PUMP '.REPAIR: <br /> _State Work Done w� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Y' <br /> Describe Material and Procedure <br /> r <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 puttingthe-well in.use... .The above <br /> information is true to the-best-of my- knowledge and belief. I WILL CALL FOR A 'GRO_UT INSPECTION <br /> PRIOR TO RROY;XGAN D A FINAL INSPECTI <br /> SIGNED TITLE <br /> # DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION" ACCEPTED BYDATEad <br /> ADDITIONAL' COMMENTS: <br /> PHASE II GROUT INSPECTION P SEI FIN INSPECTION <br /> , INSPECTION BY DATE INSPECTION $ DATE <br /> F <br /> t <br /> E H 1426 Rev. 1-74 _ f`y !x/75 2M <br />