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V <br /> SAN JOAQUIN LOCAL IiEALTii DISTRICT <br /> FOR�Ro F F ffIC E�SE 1601 E. Hazelton--Ave.-,"';Stock ton, Calif. <br /> Telephone:.' (209)vA66�6781 <br /> PLICATION FOR WELL CONSTRUCTION.,%OR RUMP PERMIT Permit No. 2X, 7 <br /> ed, <br /> THIS PERMIT -MIRES. E`-,1SS-UEDb1X.-f -ioDatd:,.I-ssu�d7 <br /> .100 <br /> Applicatio.iibi-!7,hdreby-.imade;-.tto bher.)S-ati<!.J6aquin_�Lo6al, Health- <br /> District .for: a.:peztnitfto construct z <br /> and/or install the work herein described. Thf 9 rappliatlon-%-,is,;,made.,"-i,n.�compli�aAce with San Joaquin <br /> aquir�,,-Local---Health District. <br /> -,and,-Regulatildt�s:_16f.6the San 4o <br /> County..'39rd1naii-ceoNol862 <br /> .. rand <br /> ,; -�thd!-;Rn11e6L <br /> E7.';r <br /> 'W ,� �r, <br /> JOB ADDRESS/LOCATION CENSUS _TRACT <br /> Z7;'7 6� r 1-1 <br /> .30 <br /> ;..o <br /> Owner! <br /> Address 160 :z <br /> ..... <br /> .. ... <br /> License # 3-Phone ' <br /> Contractor's Name Xtau—.7 <br /> -7 -7 <br /> TYPE OF WORK (Check) : NEW'WELL DEEPEN RECONDITION DESTRUCTION -7 <br /> PUMP- INSTALLATION -/ I PUNP> REPAIR I -PUMP REPLACEMENT <br /> Othsr_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.DI8POSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> 1 INTENDED USE -TYPE' OF WELL CONSTRUCTION -SPECIFICATIONS <br /> Industrial_ Cable _Tool,"_ r,- —Dia...-of Well Excavation <br /> Domesti.c/private. Drilled Dia. of Well Casing <br /> -'Dotnestic/public Driven Gauge of' Casing <br /> Irrigation.. Gravel Pack ' Depth. of Grout Seal <br /> Other Rotary Type of Grout <br /> Other ' Other Information <br /> PUMP INSTALLATION-. Contractor H.P. <br /> Type of Pump <br /> PUMP, REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done Li <br /> ,DESTRUCTION OF WELL: Well Diameter Apptoximate Depth <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 California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> afte:r 'completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 <br /> 4 (DRAW PLOT PtAN ON REVERSE SIDEY'A' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE II; FINAL INSPECTION <br /> I INSPECTION BY DATE INSPECTION BY <br /> N <br /> CALL POP, A GROUT- INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO,_._ <br /> 4/72 IM <br />