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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFIC I-601 E. Hazelton Ave. , Stoi kton; Calif. <br /> T&lephone: (209} 4664781 <br /> •. PLICATION. FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 'd .YEAR FROM DATE ISSUED . Date Issued? 7 <br /> `• <br /> (Complete' in Triplicate) 9 rLd <br /> Application is hereby>made,to the .San 'Joaquin Local Health District; for at to construct <br /> and/or install the work herein described. This° application is made incompliance with San Joaquin <br /> County Ordinance :No. 1862 and, the`Rules and Regulations,,of the 'San Joaquin Local Health •`District. 11 <br /> JOB ADDRESS/LOCATION <br /> &Eif CENSUS 'TRACT S;y 7 i <br /> Owner's-Name , in 'Phone ' <br /> Address L �. N <br /> . . <br /> City [r ,� .�� <br /> Contractor's Name w F` ` <br /> N �_ r c Phots <br /> TYPE 'OF-WORK (Check) : NEW TELL /)V , DEEP N / E f IONS- '] TRUCTION <br /> Other / t <br /> f <br /> i <br /> 7.' <br /> DISTANCE TO NEAREST: SEPTIC TRK SEWER LIDES ` , - PIT- <br /> SEWAGE DISPO FIELD�, G, SPOOL/SEEPA E PIT OTHER <br /> INTENDED USE F WE <br /> LL CONST PACIFIC O S / <br /> Industria] [ �tab.e Tool. D,a� of Well Excavation �O <br /> Domestic/private Dri led Di"a, of Well Casing ' <br /> Domestic/public Dri en Ga•,%ge of Casing <br /> - - Irrigation Gra <br /> R1� Degh of Grout Seal <br /> -Other - - <br /> ot Tet of.Grout' <br /> -- <br /> 0th r &hr Information <br /> PUMP INSTALLATION: <br /> of�um <br /> H <br /> .P. R. <br /> PUMP REPACEMENT:.�. / State._Work,Dong_ _ <br /> f <br /> PUMP REPAIR: / / State Work Done <br /> I <br />,DESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> Describe Material and Pro c dure <br /> I hereby agree to comply with all laws and regula ions of the San Joaquin Local Healh istrict <br /> and the State of California pertaining to or regu ating well construction: Within F FT EN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health ISistrict a <br /> WELL DRILLERS REPORT of the well and notify them Before putting the wel 'n use. The above <br /> information is to the best of y knowledge. a d belief. <br /> SIGNED ' <br /> TITLE <br /> (DRAW PLOT PA ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEP TMENT USE ONLY <br /> . '•_ <br /> if <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE iI GROUT INSPECTION �' ,. a PHASE VUFINAL INSPECTION <br /> INSPECTION-_BY-...::-. � _ �•_ _ - DATE; �+--INSPECTION`�BY - .DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO-'GROUTING AND FINAL INSPECTION. <br /> E H�1426 w w 4 4/72 1M <br /> �. , <br />