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SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> FOR OFFICE USE: 1601 B, Hazelton. Ave. , Stockto6.,, Calif. p <br /> Telephone: (209) 4boµ6781 ' 1 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 L- 3 5 S <br /> THIS PERMIT EXPIRES l YEAR FROM DATE "ISSUED , Date Issued 5- 1 "7 i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San .Joaquin Local Health Distirict for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin .! <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone 7- ,3 <br /> Owner's Name <br /> 4 l <br /> Address [o 9al <br /> _ _ City 1, <br /> 4 <br /> Contractor's Name License # id?37.3 PhoneZ�- <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN "/ / RECONDITION / / DESTRUCTION /7 i <br /> PUMP INSTALLATION 't PUMP REPA:i.R'/ / 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Z <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other ` Other Information P <br /> o- <br /> PUMP-=INSTALLATION: Contractor PH.P. <br /> f Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> TState Work Done <br /> �,—PUMP REPAIR: �_T _ _. - ....--,-J -1---:- <br /> Y :DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> 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 of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. - <br /> TITLE <br /> SIGNED <br /> k (DRAW P T PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I _r (W v DAT &17 � <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS <br /> t PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE — L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> 4/72 IM <br /> E H 1426 <br />