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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Q. 1601 E. Haielton' Ave. ,19tocktori, Calif. <br /> Telephone:.4 '(203),-466-6781 <br /> AP LICATION FOR t4ELL CONSTRUCTION40R PUMP PERMIT Permit No.7z <br /> THIS PERM17 EXPIRES 1.-YEAR 'FROMIDATE ISSUED Date' Issued 0/- 7--72- <br /> '(Complete <br /> -"12:(Complete In`Tt phi•c'&te) , <br /> Application'is,:hereby;-ma P-.-,to fhe,San �Joaquiri=Local Health District!;for- ape-imi't'-to- construct <br /> and/or install the work herein described. This sapplicationlis made 'in compliance: with -San- Joaquin , <br /> f County:Ordinance,'N6,:tr1862 '-ari�]�]t�hye`]tRules land-Regulation's -of•,the -San Joaqu'iti -Local Health District. <br /> ! rC <br /> Ziaa __ <br /> h� JOB ADDRESS/LOCATION C Aego}[..T6 N R� 1 s a L d_:h( a=CENSiJS`TRACT ': <br /> C1 :ltd r'.rj�:.. <br /> Owner's Name t"; ji`L/i:b.� La ' w iwa i :P . , t� , >< Phone K"-?W-1 All i <br /> Address•�191_ 7. City _. S el A b,6At „ <br /> i Contractor's Name °b License #4267,2V Phone !� a <br />�..�.-�.�... _ <br />( . TYPE vOF WORK'(Check}: -'NEW WELL ' -;.DEEP-EN '/ / RECONDITION / / !DESTRUCTION-/7-7- <br /> PUMP <br /> DESTRUCTION /?PUMP INSTALLATION / /'• PUMP REPAIR -/ I PUMP REPLACEMENT !7- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> %:SEWAGE DISPOSAL ,FIELD '--e'CESSPOOL/SEEPAGE"PIT OTHER <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. .of Well Excavation <br /> y� Domestic/private Drilled Dia% �of Well Casing l.1 J00.0-t6 Y)Z <br /> Domestic/public Driven Gauge of Casing,, F C ;gay/ <br /> Irrigation Gravel Pack Depth of. Grout eal. 5,; 2 <br /> Other Rotary Type of IGrout .#, C f'M f jV i <br />!S ` Other .Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. <br /> PUMPIREPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work' Done <br /> .. 0 �� pt , <br /> pESTRUCTION'OF WELL: Well Diameter �_ Approximate Depth <br /> �, {��J Describe Mat�eri�alll;aws <br /> al,and Procedu e <br /> 1>0 <br /> i€ hereby agree.-'j,-to om I ' and regulations of th an Joaquin Local Health District <br /> .and the State';."ofCaliforriia pertaining to or regulating ;weli evns.truction. Within FIFTEEN DAYS <br /> ,:,�ft-6r completion 6f my work-on anew well,' I will 'furnish the San Joaquin Local Health District a <br /> *1,*LL"DRIL1,ERS REPORT of the well and notify them before putting the well in use. ,The above <br /> �11j fiformition-is true to' the best of my knowledge and belief. <br /> SIGNED TITLE _ C N T " <br /> DRAW PLOT T PLAN ON REVERSE SIDE) ' <br /> � <br /> s FOR DEPARTMENT USE ONLY - - <br /> PASE I; <br /> APPLICATfOR ACCEPTED BY DATE <br /> 166ITI09AL COMMENTS - <br /> PHASE'. II GROUT' INSPECTION PHASE III/FINAL INSPECTION <br /> TP$GTION'BY �'O�, DATE ��, -q� _ .� INSPECTION BX , DATE 7 ' <br /> + CALL FORMA GROUT INSPECTION,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> j : H, 1426 4/72 1M <br />