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ALTH <br /> ICT <br /> SAN JOAgUIN LOCAL MES ockton�RCalif. <br /> For. OFFICE USE: 1601 E. Hazelton Ave. , <br /> Telephone: (209) 466-6781 Permit No. <br /> E9 <br /> APPLICATION APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT T ---1 <br /> Date Issued 7 <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ,ISSUED ��-� <br /> (Complete In .Triplicate) permit to const'�uct <br /> Application is hereby made to the San. Joaquin LocalisHealth tmade inrict rcompliance with San Joaquin <br /> and/or ins�all the work herein descried. " This application <br /> County <br /> Ordinance No. 1862 and the Rules and Regulations^1f the Sari Joaquin Local: Health District. <br /> CENSUS TRACT <br /> ,JOB ADDRESS/LOCATION S <br /> � + Phone <br /> Owner's Name +�- �` <br /> f . City <br /> Address . <br /> Q License 11 _ Phone <br /> Contractor's Name .JV/ <br /> TYPE OF WORK (Check) : NEW tdELLDEEPEN 1_�/ <br /> RECONDITION / / DESTRUCTION /7PUMP INST�TION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other L-1 <br /> SEPTIC TANKSEWER LINES PIT PRIVY <br /> DISTAiNCE TO NEAREST: SEWAGE DISPOSAL .FIELD _�_ CESSPOOL/SEEPAGE PIT OTTER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRICTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. of Well Excavation O <br /> f <br /> Domestic/private v Drilled Dia. of Well Casing -- <br /> Domestic/p Driven Gauge of Casing <br /> Domestic/public <br /> _ Gravel Pack Depth of Grout Seal <br /> Irrigation <br /> Rotary Type of Grout <br /> f <br /> other Other Other Information <br /> k. <br /> PUMP INSTALLATION: Contractor H,P. <br /> Type of Pump <br /> PUMP REPLACEMENT: L/ <br /> State Work Done <br /> G _ <br /> i PUMP "U;PAIR: / / State Work Done <br /> I DF�TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> 5 Describe Material and Procedure <br /> M I hereby agree to comply with all laws and regulations owell�•constructsan.Local <br /> WithinHealth <br /> FIFTEENDistrict <br /> DAYS <br /> i <br /> and the State of California pertaining well, <br /> or I regulating <br /> after completion of my work on a new wel�ify temlbeforesputtingh the atheo�rel�ninouse.HeThehaboverict <br /> 14ELL DRILLERS REPORT of the well and nkn.owled e and belief. <br /> Ilk information is true to. the best of my S F <br /> TITLE <br /> SIGNED {DRAW PLOT PLAN'ON .REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i P1xASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PIiAS /FINAL INSPECTION <br /> ' PHASE I GROUT INSPECTI N INSPECTION BY DATE O^ � 4 <br /> INSPECTION BY DATE W <br /> CALL FOR A UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br />