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SAN JOAQUIN LOCAL I3EALTU DISTRICT 4 <br /> 1601 E—Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: 209 466-67$1 <br /> Telephone: . ( } No <br /> it . Z' 1 <br /> PLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT PermL �O -S <br /> THIS PERMIT EXPIRES l YEAR FROiDate�f DATE ISSUED <br /> Issued b 3 -7 L <br /> (Complete In Triplicate) <br /> A lication .is -hereby;made to the San Joaquin Loaall�catonDistrict made inr".a permit compliancetwith SanJoaquin construct PP <br /> and/or install ,the work herein described. This PP <br /> 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance,No. . > k. <br /> ' CENSUS TRACT , <br /> ,TOB ADDRESS/LOCATION � � _ - <br /> h . Phone <br /> Owner'.s :Name , <br /> City <br /> Address - ` <br /> License � � Phone <br />{ Contractor's Name <br /> s <br /> ' <br /> RECONDITION DESTRUCTION 7 <br /> / / <br /> TYPE OF WORK (Check) . - NEW WELL `/�-/ tDEEPENPUMP REPLACEMENT /7 <br /> AL <br /> •. „. PUMP INSTLATION / PUMP REPAIR / <br /> Other <br /> - SEWER LINES PIT PRIVY F <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOO SE PAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD )\1 <br /> A !'.- <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> _ Industrial Drilled Dia. of Wel Casing <br /> Domestic/private Gauge of 'Casing eal <br /> Domestic/public Driven $ . ; , <br /> . Gravel Pack Depth of .. rout S <br /> Irrigation <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor H.P. <br /> k Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> 6, <br /> PUMP REPAIR: State Work Done - <br /> -_-�.�--� T��---- I Approximate Depth <br /> •DESTRUCTION OF WELL: Well Diameter . . <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of <br /> San Joaquin Lo <br /> 11construction. Within cal aDistrictlth <br /> FIFTEEN DAYS <br /> and the State of California pertaining to or regulating <br /> we <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 knowledge and belief. <br /> TITLE <br /> SIGNED ' ' (DRAW P PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/ IN INS PECTI N <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A_ GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 ' <br />