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SAN JOAQUIN LOCAL !UZALTH DISTRICT <br /> FOR OFFICL USE: 1601 E. Hazelton':Ave.;r=Stockron Calif. <br /> Telephorie:,.,..(209)`%'4664 781 <br /> APPLICATION FOR WELL CONSTRUCTIONLOR PUMP PERMIT Permit No. 72-,4 y a <br /> THIS.PERMIT,ZXPIRES'1 .YEAR'`.rR0,"i5'DATE`•ISSUED r <br /> to I'ss ed � 7Z � <br /> .(Complete Tfi -Triplicate) <br /> Application 11d-herebysmadeIto thetS,an'.:;'Joaquin-Local Rea-11th D: str'ict:'.for,a,permit 'to .construct r <br /> and/or install the work herein described. 'Thi'6 applicat on is made�in :compliance with San Joaquin <br /> County-.Ordinance..No:c°1862r,andNthe-£Rulesa-and ,Regulations �of°the•Sari''Joaquin",Local�Health District. <br /> JOB ADDRESS/LOCATION X&M 13152 Dro e CENSUS--TRACT F. < <br /> 74a <br /> Owner'.s Mame'' If) zu.i E�rt1031 EIEn{.F1 n ? Y :Y h t f [+:'.0 i:'!3 <br /> Address 1.3152. Droge Rd, City EscaQ�is. <br /> _.. . <br /> .838-7570 <br /> Contractor's Name John Panerg: License # 120724 Phone 886 5400 <br /> TYPE OF WORK (Check) : NEW WELL/) �DELPEN11 / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR '/' / PUMP 'REPLACEMENT <br /> Other: / ! r I <br /> DISTANCE TO NEAREST: SEPTIC TANK54t SEWER LINES PIT PRIVY t � ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -MOM' <br /> i INTENDED 'USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a xCable Tool Dia. of Well Excavation tt <br /> 2- ___condlaco_r_ <br /> x Domestic/private` Drilled Dia. of Well Casing <br /> Domestic/public Driven ' Gauge: of Casing 1�ti O <br /> Irrigation Gravel Pack Depth: of Grout Seal 52 <br /> Other Rotary Type of Grout cement <br /> Other Other Information <br /> PUMP INSTALLATION: ' Contractor <br /> Type .of Pump H.F. <br /> PUMP REPLACEMENT: / /.E :State, Work Done <br /> PUMP REPAIR. / / ..State Work,Done <br /> ,pESTRUCTION OF WELL: Well Diameter 6 ' <br /> .__...��& Approximate, Depth 70L <br /> Describe Material and Procedure cementinp�'- <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 /> SIGNED TITLE Owner <br /> (DRAW PJ40T PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I �- <br /> APPLICATION ACCEPTED B (1 DATE s� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAAE,III/FINAJ,,o INSPECTION <br /> INSPECTION BY ^� DATE �;-Z-�2 INSPECTION BY WSJ DTE <br /> CALL FOR A GROUT INSPECTION PRIOR _TP GF <br /> OUTING AND F FINALINSPECTION., �f_ <br /> E H 1426 �r � [� 1 11l 4/72 1M <br />