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SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> FOR OFFICE USE: V/1601 E. -Razelton:,-'Avb. ,'1.".'St"ocktori, Calif.
<br /> Telephone.:1-,,,'-(209)A'4.66_;16781
<br /> APPLICATION FOR WELL..CONStRUICTIONAOR PUMP PERMIT Permit
<br /> THIS PEPMl..Tl.EXPI.-YES,;l,- YEA.R,,IPROM-,:,,DATFftIS-S-UED'-,'.�! '1cDate-1,9§u6d.
<br /> Applicati:oriL-ir;'!;hdreby-,madei-fto lEh-eic�S-an�,J.oaq.uia',zLo6a:l, Health
<br /> and/or install the work herLn described. Thi:"6�apPltcatlon,,'is 1-made `1nc-,corhpl!iAAc6,,with SAn.',,Joaquin
<br /> I
<br /> County!"Ord,inaiftcec3NO.:.,7,1862.,,,-a'nd,,tithd.-Ru.l-a§'.}and-.,-Re-gulat,i:(5ns-'�6f,;the_.,Sati-',
<br /> Joaquin L6ca1056&,lth, District;
<br /> JOB ADDRESS/LOCATION cCEN.STjS,iT-RACTi0
<br /> na RC
<br /> Owner'.g sKamii,' .
<br /> 4?
<br /> ,Address
<br /> Gi_tT.
<br /> Contractor's Name
<br /> s, -�Phone.!��,"!P
<br /> License ftZao 7
<br /> TYPE OF WORK (Check) : NEW WELL -K DEEPEN RECONDITION DESTRUCTION J_7
<br /> -7
<br /> -PUMP INSTELATION PUMP REPAIR
<br /> / / PUMP REPLACEMENT
<br /> Other
<br /> DISTANCE TO NEAREST,: SEPTM TANK SEWER LINES PIT PRIVY"
<br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ; . OTHER:
<br /> INTENDED USE =PE OF WELL
<br /> %. CONSTRUCTION SPECIFICATIONS
<br /> Industrial:. i_ Cable Tool Dia. of Well Excavation A9
<br /> Domestic/private 11 Drilled Dia. of Well Casing
<br /> Domestic/publicDriven � Gauge of Casing 'e,
<br /> Irrigation. Gravel Pack Depth, of Grout Seal 1-5'0
<br /> Other Rotary , Type of Grout
<br /> OtherOther Information ' "
<br /> PUMP INSTALLATION: Contractor
<br /> Type 'of Pump 4
<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 hereby agree to comply wieh .all laws -and regulations of the San Joaquin Local Health District
<br /> and the State of Californialopertaining to or' regulating well construction. " Within FIFTEEN DAYS
<br /> afte,r completion of my woiki7oh a new well, I will furnish the San Joaquin Local Health District a
<br /> WELL DRILLERS REPORT o the ,',well and notify them before putting the well in use. The above
<br /> information is true
<br /> t..e b of .mnowledge and belief.
<br /> SIGNED 'TITLE -
<br /> (DRAW OT PLAN ON REVERSE SIDE)
<br /> FOR- DEPARTMENT USE ONLY
<br /> PHASE I
<br /> APPLICATION ACCEPTED BY DATE
<br /> ADDITIONAL COMMENTS. j
<br /> PHASE II GROUT ,.INSPECTION PHASE JI V.F INAL INSPECTION
<br /> INSPECTION By ;DATE A_Aa.- *U6 INSPECTION BY DATE
<br /> CALL FOR A GROUT INOECTION PRIOR T.0 GROUTING AND FINAL INSPE6ON*
<br /> E H 1426 4/72 1M
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