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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOFOFFICE 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) <br /> Application is her y made to the Saiz 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 a_ndgulations of the San Joaquin Local Health District. <br /> f 6 -7-� <br /> i JOB ADDRESS/LOCATION, �,� - CENSUS TRACT.' <br /> s% evAlzm <br /> Owner's Name Phone `" <br /> Address City <br />` Contractor's Name License # hone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN Cl RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / -PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indu'stri.al•. ' " Cable Tool Dia, of We11 Exc-aviation <br /> Domestic/private ' . Drilled ""'—D—ia: of`Well <br /> Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout v <br /> .Disposal Other, : Other Information � <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorOL <br /> Type of Pump H.p. ' <br /> PUMP REPLACEMENT: J - - <br /> State Work bone / / <br /> PUMP -.REPAIR: / / State Work Done <br />' DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ppi <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 tr to the b of my knowledge and belief, I WILL CALL FOR A. GROUT INSPECTION <br />' PRIOR TO GRO TING D A FIN "SPEC IU . <br /> SIGNED _ TITLE <br /> 41— (DUW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY 0 <br /> PHASE I <br /> APPLICATION ACCEPTED BYWDATE <br /> � DATE 9Z--;;� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE I I/FI AL INSPECTION <br /> INSPECTION BY INSPECTION BY BATE Io y <br /> E H 14.26. _Rev 11--74 <br />