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SAN JOAQUIN LOCA; �:E.ALTH DiRI <br /> �: .- <br /> FOR OFFICE USE: 1601 E. Hazelton Av'. Stocicxor Calif. <br /> Telephone: (209) 466`-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z, W 75 <br /> .1 F� <br /> THIS PERMIT EXPIRES" 1 YEAR FROM DATE -ISSUED ;. Date Issued <br /> I <br /> (C6mplete 'In Triplicate) <br /> Application is h reby made ` o the -San Joaquin Local health District 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 /> JOB ADDRESS/LOCATION lC� CENSUS TRACT <br /> Owner's Name <br /> Phone ' <br /> Address . <br /> City <br /> Contractor's Name � ,� " fi � License <br /> 14 <br /> TYPE OF IdORK (Check) NEWLL WE ` EEPEN "J / PRECONDITION /_-7£ DESTRUCTION / <br /> a PUMPJINSTAL ATION /�J PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other' <br /> t <br /> DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITC__ OTHER <br /> IN'T'ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial ;_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ✓� <br /> Irrigation Gravel Pack Depth of Grout Seal . . <br /> Other i;- Rotary Type of Grout__- <br /> i Other Other Information " <br /> 4 _'N: "� 3 <br /> PUMP INSTALLATION.- Contractor, - k �, �•P�Rrct-e�� <br /> Type of Pump H.P. <br /> PUMP''REPLACEMENT: /% "State Work Done <br /> PUMP REPAIR: / / -State Work Done <br /> ;DESTRUCTION OF WELL: W II � er i <br /> Describe Material and Procedure " I <br /> I hereby agree to comply with all laws and regulations of the San•,,Joaquin Local Health District <br /> and "the State of Calir- <br /> foni"a4.pe-rtaining"-to or regulating well construction. Within FIFTEFIi DAYS <br /> after -completion of my work:'on a new well,."I; -rill 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 /> a r <br /> SIGNED ! ? TITLE �C: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY j..' - - DATE �`.:3� 72— <br /> _ --- - - <br /> ADDITIONAL. COMMENTS: <br /> PHASA II GROUV INSPECTION PHASE . II/FINAL INSPECTION <br /> INSPECTION BY ,DATE / _ INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - ; 4/72 1M <br />