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SAN JOAQUIN LOCAL FiEALTI1 DISTRICT <br /> FOR OFFICE USE: I1601 E. Hazeltori``Ave. 1,,Stockto;.-t, 'Calif.' <br /> Telephone:;_:.. (209)1•t.466�-6781 <br /> PLICATION FOR WELL CONStRUCTION:'OR PUMP PERMIT Permit No. Z-S 7� <br /> ._ el4566 <br /> THIS PERMIT tEXPIRES,,.l!YEAR', ROM:,DtATF -ISSUED o Date Issued 6 ­7 7— <br /> no <br /> no°.►^► , (.Complete Ihi-Triplicate) %'t_ <br /> ' <br /> Application,, s-hereby_imade 'to tihe„San rrJoaquin'Local Health Di.strict:fore-a`permit"to` corristruct <br /> and/or install the work herein described. Thisr:application�is.'made:in ;compl'iance-with ,San•Joaquin <br /> County�prdinancecNo.(il862 s.'and-;�thec�Rules Rand,=Regulations=:6f,,,,the, San,Joaquin Local`'Health''District: <br /> 3 . � erseL41r .o ; , . <br /> JOB ADDRESS/LOCATION I�T�'��T� ;r S- CG U&TRY .C1 0,6 _ CENSUS,TRACT.� <br /> !',I)L q x:31 "'T C, :,>riE, <br /> Owner's. NameW f '�o c1.11" w7z5-V _ 6 4 .1-7,' Phone' <br /> Address C BA 9/T' _ city <br /> Contractor's Name Z f a t2/P CG License # G 60 ZPhone G2--MS`S,97 <br /> k TYPE OF WORK (Check) : . NEW WELL/ / DEEPEN `/ / RECONDITION l_T 'DESTRUCTION /_7 <br /> i PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL' Z CONSTRUCTION SPECIFICATIONS - <br /> Industrial, Cable Tool Dia. of. Well Excavation � _ _,W � <br /> Domestic/private: Drilled > Dia. of Well Casing a <br /> Domestic/public Driven ' Gauge' of Casing <br /> A ---ftrigation a ...Gravel.:Pack . Depth of Grout Seal <br /> Other 4:--Rotary _ Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / '/ State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL. . Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I he'rebyagree 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 of the well and notify them before putting the well in use. Theabove <br /> information is true. to. the best of'_my :knowledge ''and' belief. . <br /> ' `l .TITLE. <br /> SIGNED _ _ � , � � _ �. <br /> (DRAW `PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE. I r <br /> APPI�ICATION ACCEPTED BY <br /> _ADDITIONAL F COMMENTS <br /> PHASE II --GROUT INSP TION `' PHASE-•III/FINAL INSPECTION <br /> k INSPECTION BY DATE _ INSPECTION BY T,)-Ktl DATE __4t -Lzj- r <br /> CALL FOR A GROUT INSPECTION_PRIOR_TO GROUTING AND FINAL INSPECTION. .M„ s <br /> E H 1426 _ - 4/72 1M <br />