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// I <br /> r'Y/C/YSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> )q 7k, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED Date Issued g;j4__ � <br /> (Complete in Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District fora 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 ar€d the Rules Regulations of the San Joa uik <br /> c 1 He0th District. <br /> JOB ADDRESS/LOCATIO p CENSUS TRACT <br /> Ownerps Name i Phone <br /> k ' .. <br /> Address G ILA City1AA1A'1_A� _C4. <br /> Contractor's Name f License # O Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/ CONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR /� PUMP REPLACEMENT <br /> Other' / <br /> f r <br /> DISTANCE TO NEAREST: SEPTIC TANK R LrES IT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD)/�ESSPOOL/SEEP�GE PIT OTHER <br /> PROPERTY -LINE - PRIVATE DOMESTIC WELLI-2 PUBLIC DOMESTIC WELL <br /> INTENDED USE krTYPE-OF WELL �. CONSTRUCTION SPECIFICATIONS Q <br /> In trial ; Cable Tool Dia. of Well Excavation P/ <br /> i <br /> Domestic/private Mi Drilled. Dia. of Well Casing <br /> ¢ Domestic/public ( I Driven Gauge of Casing �- <br /> 4 Irrigation +1 Gravel Pack Depth of Grout Se` <br /> Cathodic Protection _ .. .1�-totary Type of Grout, ' • <br /> Disposal i Other Other Information <br /> Geophysical. "� Su a Seal Installed—'By': ' CA <br /> PUMP'~ N�.x'ALI.ATION: Contractor <br /> /Type of Pu _ <br /> PUMP REPLACEMENT: / / State Work'`Done <br /> PUMP '.REPAIR: /_7 State fWdrk-one,, <br /> 41 <br /> ,�3_ESTRUCTION OF WELL Well Diameter , Approximate Depth <br /> .. j <br /> Describe Material and Procedure — <br /> I hereby agree to- comply with all laws and regulations of�the San Joaquin Local Health District <br /> t and the State of California pertaining to�or regulating well}construction. Within FIFTEEN DAYS <br /> after completioniof my work •on a new well, I will ^furnishe.the _San Joaquin,.Local Health District a <br /> WE L DRILLERS REPORT of the..,well andfnotify' them before putting.thd_well in use.. The above <br /> in tion is trueto the' 'm kxowladgeµ,and belief:"'I WII:L"CAI;I: FORA GROUT INSPECTION <br /> PRIOR ROUTING•AND AL _ CTI <br /> SIGNED ! 1' TITLE B L <br /> �k j W PLOT P REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I- . <br /> I APPLICATION ACCEPTED BY DATE .'�L <br /> ADDITIONAL COMMENTS: .� �, '" r _ ►: , s , "' <br /> / PHASE II GROUT INSPECTION 1PHASE III' INAL INSPECTION <br /> .DATE —INSPECTION BY DATE - e� <br /> � INSPECTIiN, BY ` � � r • , � <br /> F i ryE H 1426 Rev. 1 74 .; - ,� 1 \ :. �,�,.1'-74 2M <br />