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/� SAN JOAQUIN LOCAL._HEAI;TH- DISTRICT <br /> FOR OFFICE USE: eV 1601 E. Hazelton Ave:', `Stockit n, Calif. � <br /> Telephone: (209) 466-6781 - 4, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT f?,-Rermit No. 17,6 <br /> THIS. PERMIT EXPIRES 1 YEARFROM DATE ISSUED Date Issued <br /> (Complete :In Triplicate) <br /> Application is hereby made--totheSan Joaquin Local=;Health District for a permit to construct <br /> .and/or install the work herein described. This -application:is made in compliance with San Joaquin <br /> County Ordinance .No.. 1862. and the Rules and Regulations-of .the'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> w <br /> Owner's Name Phone 473lg-e;2*,!�Z <br /> Address L-Ey 0e4l_ City <br /> I Contractor's-Name- - ,,,. `-. License -Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /7 RECONDITION /_7 DESTRUCTION X <br /> PUMP INSTALLATION / / PUMA REPAIR /-7 PUMP REPLACEMENT <br /> i Other / / <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFI TIONS <br /> Industrial . 'GGable Tool Dia. of Well Excavation <br /> r/�7omestic/,private; Drilled Dia. of Well Casing �r <br /> a Dohestic/public" Driven Gauge'.of Casing 49 ��.. <br /> Irrigafion E Gravel Pack Depth:: of Grout Seal S/J <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1P _' Other Other Information <br /> l <br /> GeophysicaSurface Seal Installed By: <br /> PUMP INSLLATION:, ' Contractor <br /> Type of Pump H.P. '7•,y <br /> PUMP REPT CEMENT.: / / State Work Done E r a \ <br /> PUMP REPAIR: r �- State Work Done - f <br /> 4ES•TRUCTION OF WELL:, ' Well Diameter ld " Approximate Depth ZO� <br /> escribe Material and Procedure 5D� <br /> I hereby &gree 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 ofYmy wor-k on-anew well,-Iwill-furnish.-the San Joaquin Local Health District a <br /> WELL DRILLERS EPORT 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. . I WILL CALL FORA-GROUT INSPECTION <br /> PRIOR TO GROUTIN ANJD A FIJNAL INSEgg.19N, <br /> f SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE - �- <br /> ADDITIONAL COMMENTS: <br /> ro INSPECTION PHASE_III .FINALINSPECTION.INSPECTION-BDATE_ _ " °'" +.. � . INSPECTION BY DATE �fE H 142 . 74 1-74 2M <br />