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/ SAN JOAQUIN LOCAL HEATH DISTRICT <br /> ror ICE SE: 1601 E. Hazelton Ave; , 'Stockto , 'Calif1. <br /> Telephone: (' (209) 466 6781`2 Permit No. 776�� i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ! <br /> THIS PERMIT EXPIRES' 1'YEAR PROM DATE ISSUED '' ' Date Issued <br /> (Complete in Triplicate) ;'', r 1 <br /> Application is hereby made to the San Joaquin Local Health Dlstrict. for. A permit to construct <br /> and or. install the work.herein described. This applicat on,is ,made.:ia compliance with San Joaquin <br /> Count or, No $6Z.rand-the .Rules and Regulations.of�-the'. �San Joaquin- Local Health District. <br /> County �y..� j� <br /> 7-33_s. Ght' moo- - 10S9--4 <br /> �. CENSUS TRACT <br /> JOB ADDRESS/LOCATION .� <br /> Phone ; <br /> Owner's Name <br /> city <br /> Address <br /> cense -Phone-- 4_2 <br /> Con}tractor's Zame- <br /> -rt-.-rte.: '^_'r+_. � _.. .���_..7i-�•' r �� <br /> TYPE OF WORK (Check) : W WELL;/_A. DEEPEN / RECONDITION /?P DESTRUCTION f7 ; <br /> PUMP INSTALLATION /�.f�UMP REPAIR /� PUMP REPLACEMENT <br /> Other /_7 a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESs %\'4.:`)'.PIT`PRIVY . 4 <br /> J SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE P`IT'`' OTHER , k <br /> # ..1'RO FxRTY LINE�--PRIVATm <br /> E` MESTIC-WELL , ; PUBLIC DOMESTICWELL � <br /> INTENDED TYPE OF WELL CONSTRUCT-105-.SPECIFIC&TIONS t�\1 <br /> able Tool Dia. of.Well Excavation / _ <br /> ii ` industrial. r • �: - w <br /> rpoestic/pr�vae - Drilled Dia." of We11 Casing <br /> /Domestic/publi'c��'" <br /> Driven Gauge. of Casing e- <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> !' Rotary- Type -of Grout ; <br /> Cathodic Protection Y' !' <br /> Other <br /> Information . <br /> u;: r Disposal Other <br /> Surface Seal Installed B` •' j <br /> Geophysical <br /> �. <br /> PUMP INSTALLATION: Contractor <br /> -Type of Pump = y <br /> f PUMP REPLACEMENT: 1 I State Work Done <br /> PUMP :REPAIR: / State York.Doner <br /> Approximate Depth <br /> ES:TRUCTION OF WELL: Well Diameter <br /> Describe-HatertIl and 'Ptocedure <br /> ,;i. 3 c <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 DAMS <br /> aft`ex 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.. <br /> The above 1 <br /> information is true to the best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRN A I ON. TITLE ? <br /> SIGNED Of, 00, <br /> (DRAW PLOT,.PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i " DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II. GROUT INSPECTION __ <br /> �-INSPIGTION ,By - - r- -DATE <br /> i $NSPECTION BY 3-- <br /> 4 E H 1426 Rev. 1-74 0 �` - - <br />