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ca <br /> SAN ,tOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE: USE: {s <br /> "�--- 5 I60, i.. Hazelton Ave., Stockton, Calif. <br /> - '-""-�- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 17 <br /> ":fIS PERMIT EXPIRES 1 y1AR FROM DATE ISSUED Date Issued <br /> Applicetxon is (Complete In Triplicate) 4-22-A <br /> Hereby made to the San Joaquin Local Health District for a permit to Conatru <br /> ct <br /> and/or install the work here.n described. This application is :Wade in compliance with Senn joaqj. <br /> County Ordinance No. 1862 and the Rules a d Regulations of the San Joaquin focal <br /> JOB ADDRESS/IPCATION N�VN viou� lF p-f-- <br /> alth District. <br /> reiW <br /> Rx <br /> Owner's Name <br /> Phone , <br /> Address �- <br /> City ..�._.�,_ <br /> Contractor's Name }> <br /> License /_j0fMj Phone <br /> TYPE OF WORK (Check): _NEW WELL /-7 DEEPEN / RECONDITION./7 DESTRUC'T'ION <br /> s PUMP INSTALLATION �� REPAIR �'. <br /> Other j / /? PUMP REPLACEI�NT'J9 <br /> r� <br /> 't DISTANCE TO NEAREST: SEPTIC T.ANK � $ <br /> SEWER LINES PIT PRIVY <br /> ?, SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE. PIT <br /> HU <br /> PROPERi.Y LINE -� PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> w, INTENDED USE TYPE OP WELL - WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation ' <br /> Domestic . � <br /> a — /Private Drilled Dr <br /> Domestic/Public Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <br /> >: Rotary Type of Grout <br /> Dispor. -11 Other , . <br /> Geophysical �.r Other In,?ormatlen <br /> 4 Surface Sea Ins <br /> PUMP INSTALLATION: Contractor <br /> Type of rump <br /> j; <br /> PUMP REPLACEMENT: <br /> L/ State Work Done <br /> PTIMP -REPAIR: <br /> / State Work Done �4 <br /> DE,S-TP CTI4N OFWELT,: Well Diwmeter <br /> Describe Material and Procedure ApProximat6 Depth €' <br /> "---��. <br /> I <br /> I hereby agree to comply with all laws and regulations of on a ne w the San Joaquin Local Heaiatrict <br /> lth <br /> and the State of California to or regulating well construction. Within FIFTEEN nATg ' <br /> WELL DRILLERS <br /> after completion of my work on fl new well, I will furnish the San Joaquin Lucal Health District a <br /> RT of the well and notify them before putting the well in use. The above <br /> informatio <br /> e o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO A FINAL, INSPECTION. <br /> SIGNED <br /> 4 DRAW PLOT PIAN ON REVERSETLE <br /> SID P <br /> PHASE I �FUR DEPAR MENT USE ONLY � <br /> APPLICATION ACCEPTED BY � l� �/ y[ o <br /> ADDITIONAL COMMENTS: ' DATE <br /> PHASE Ii GROUT IN'. 1 ` TION PHASE II FINAL INSPECTlOi7 <br /> INSPECTION BY � DA_ INSPECTION BY/ <br /> ATE ' <br /> E H 1426 Rev. 1-14 <br /> 1177 . 2N <br /> i <br />