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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR O ICE USE: < 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> La-4 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED Date Issued ?6 <br /> (Complete In Triplicate) <br /> Application is hereby made t? 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 anA .the Rules and Regulation:04�e 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,3� /�r. ¢ $� CENSUS TRACT <br /> Owner's Name S 6 Phone <br /> Address <br /> Y ¢`t City o . <br /> r <br /> Contractor's Name zvi ► License #,,9. 2 is�hone jq2---7G 76 <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN '/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other L/% <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 /> Industrial i Cable Tool Dia. of Well Excavation # <br /> _ Domestic/private F Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing C <br /> Irrigation I Gravel Pack Depth of Grout Sea_l- <br /> Cathodic- Protection' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> k <br /> PUMP INSTALLATION; Contractor-'. <br /> Type of Pump 7� /,6 H.P. <br /> PUMP REPLACEMENT: , f <br /> /x/ } State.Work Done <br /> PUMP .REPAIR: / / 'State Work Done <br /> DESTRUCTION 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 true to the best o my-know-led and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO UTING AND A FIN E I 17, <br /> SIGNED Q_,�ITLE <br /> DRA P ZT PLAN ON FRSE SIDE) <br /> FOR DEPARTMENT'USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II G U MSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE CT- Fj <br /> E H 1426 Rev. 1-74 R,.; 3/76 <br />