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SAN JOAQUIN<LOCAY HEALTH I T <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , St 99co Ca if. <br /> Telepho (2 9�j 4'ff6= 1 .'V <br /> APPLICATION FOR LLCRIICT 0 UMP Permit No. 7 �//cab✓ <br /> IVli <br /> THIS PERMIT XPIR S 1 ROM DATE I SUED Date issued T� 4 <br /> ( plet Triplicate) T <br /> Application is hereby made to the San JoaquVisoapplicaition <br /> cal. Health District for a permit to construct <br /> and/or install the work herein described. is made in compliance with San Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Y31 Ca-ycn. 2oG4-4-�r CENSUS TRACT <br /> Owner's NameAles ,x ' Phone <br /> Address 3/ co- .�'-�u�lr4 !I City <br /> •I <br /> Contractor's Named �iie y �Lia1�2r�.,� � <br /> dLicense # Phone <br /> TYPE OF WORK (Check): NEW WELL X DEEPEN /_/ RECONDITION /- DESTRUCTION /� <br /> PUMP INSTALLATION 0 PUMP REPAIR / / . PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' I <br /> Industrial Cable Tool Dia: of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing 4_ `" <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other A-- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor „ Cr ctc--� <br /> Type of Pump gj. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRS / / State Work Done <br /> 4 <br /> .D -f <br /> ESTRUCTION OF WELL: Well Diameter s Approximate Depth v`� <br /> Describe Material and Procedure, <br /> E <br /> I hereby agree to comply with all laws and regulationsaof 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 knowledge and belief. <br /> SIGNED fi L,/ TITLE �' &y f- s2 ry <br /> CZ (DRAW PLOT PLAN ON.; REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I '" <br /> APPLICATION ACCEPTED AT <br /> . ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I PUNSE III FINAL INSPEC ON <br /> ' INSPECTION BY DATE INSPECTION B DAT <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INS -----� <br /> E H 142672 IM <br /> ;t <br />