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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 <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 JoaquiT <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / B'�G CENSUS TRACT <br /> Owner'sName l .� Phone <br /> Address Cit <br /> � Y G� <br /> Contractor's Name r <br /> License #/ Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION <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 /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public I 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 /> Geophysical <br /> Surface Seal Installed By: <br /> ' x� <br /> PUMP INSTALLATION; WContractar <br /> Type of Pump .5 H.P. <br /> PUMP REPLACEMENT: . � Done - <br /> PUMP <br /> r _ <br /> �/ 'State Work Done _ <br /> PUMP .REPAIR: f-77 "'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 of my.. owledge and belief: I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AN A FINAL ECT ON. <br /> SIGNED <br /> W:17LOT p 'ON REARSE RSE SIDE) ; <br /> PHASE I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: A = <br /> PHASE II GROUT PECTION.- PHA I /F AL NSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE '. <br /> E H 1426 Rev. 1-74 376 2M <br />