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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk.OFFICE USE: /� 1601 E. Hazelton Ave'. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- <br /> ' (Complete In Triplicate) <br /> Application is Aereby 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 Son Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS AOCATION QYOL Alizi ntlt, CENSUS TRACT <br /> Owner's Name 12 It. 5a 4" b8c"Ic, Phone 9 3 2r-27,13 <br /> Address m ie City ' ILS C,448A.1' <br /> Contractor's Name ij�- ,J License # .7907C?hone <br /> TYPE -0,FWORK._(Cheek-WORK ---NEW WELL / DE9EEN -/—RECONDI.TION_/�..�...-DESTRU.CT,ioN-/�f <br /> PUMP INSTALLATION / / PUMP REPAIR /XPUMP REPLACEMENT /7 <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 z CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool t Dia. of Well Excavation �l <br /> Domestic/private Drilled Dia.,of Well Casing <br /> Domestic./public- Driven Gauge of Casing <br /> Irrigation "` Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type., of Grout_,__. _ <br /> Disposa'1 Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> �y Type of Pump <br /> PUMP REPLACEMENT r / / State Work Done <br /> i <br /> PUMP .REPAIR: 4W State Work Done ' I r <br /> AESTRUCTION OF WELL: Well Diameter eL Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to Comply with all laws and regulations of the San Joaquin Local Health i$tr_ ct , <br /> and the State of California pertaining to or regulating well ''construction. Within FIFT99N 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-knowle.d.ge_and--bel.-:ef.—I-WILL- CALL . .OR A GROUT INSPECTION <br /> PRIOR TO GROUT G ANDAaINA,L INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN, ON REVERSE SID4, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASZ III/!FINAL INSPECTION( <br /> INSPECTION BY s it' DATE INSPECTION BY DATE <br /> 1177 2M <br /> E H 1426 .. Rev, 1-74 - ,- <br />