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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE�� OFFICE USE: 1601 E. Hazelton:rAve`.`;-<S ockL'c-a, Calif. <br /> Telephone: „'':(209) '..466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION'.OR PUMP PERMIT Permit No. <br /> 4 7 <br /> THIS PERMIT�'EXPIRES;;l,YBAXt; FROM,,DATE LSSUED Date Issued-wT <br /> 2� <br /> (Complete l i` `Triplicate) a <br /> 4 Application;is).hereby.-made,xo ;the)San,Joaquin:' Local Health District for a permit to construct <br /> and/or install the work herein described. Thik,,vapplic.a ion is.made in compliance with San Joaquin <br /> County3,Ord'i,nance4No -1$62..and,,IthetRules and Regulations o'f',the San 3 quip Local Health District: <br /> i,'r[a <br /> E ,TOB ADDRESS/LOCATION 1­i,' <br /> rte-- r � <br /> a CENSUS TRACT <br /> {. A (�J7 f,[�' /i/�� 72— <br /> Address <br /> � �/�..]�. —/�/ 7 <br /> 4 Owner.'s a Name7. /L' /moi \O.r"/ I 9 Ir,,, dfi ) Sn .$:.> i 6— — J <br /> / Dr-� `� Phone <br /> AddressttlQ DAP. 5SZ City 0 <br /> Contractor-.'s Name <br /> License #,20 15 Phone <br /> _ r <br /> TYPE OF WORK (Check) : NEW WELL:_0 DEEPEN/_/ RECONDITION /_7 DESTRUCTION /-7 <br /> 4 PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT F ./_-'= <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL, FIELD -- CESSPOOL/SEEPAGE PIT OTHER <br /> { INTENDED USE , TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool Dia. of Well Excavation Q <br /> i Domestic/private Drilled Dia. of Well Casing <br /> Domestic/pciblic - Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal `13 <br /> Other+'' Rotary Type of Grout e) &)4;—:: _ <br /> {F Other Other Information 11) <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rpt(L%, w -- <br /> H.P. <br /> a _ <br /> PUMP REPLACEMENT: / / ' State WorkDone <br /> PUMP REPAIR: / / State Work Done <br /> " s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` T Describe Material. and Procedure <br /> I hereby agree,to comply with all laws and regulations of 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 �f the well and notify them before putting the well in use. The above <br /> information is o th est of my knowledge and belief. <br /> f <br /> i <br /> SIGNED TITLE <br /> L7 �,e�/7X— <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,y,,,__ fes' DATE 6' <br /> ADDITIONAL COMMENTS.: <br /> PHASE" II GROUT INSPECTIOW AAL INSPECTION pp <br /> INSPECTION BY +',.. DATE INSPECTION BY DATE1OJi <br /> CALL F'OR A.GROUT_INSPECTIQN .PRIOR.,T.O GROUTING AND FINAL I CT ON. <br /> E H 1426. 4/72 1M <br />