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SAN JOAQUIN LOCAL HEALTH DTSTRICT � <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,tStocktc)n, -Calif. <br /> Telephone: (209). 466-6781 I <br /> APPLICATION .FOR WELL CONSTRUCTION..OR PUMP PERMIT Permit No. 7Z,- 57 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate') <br /> Application is hereby-made-,.to the San,Joaquin-Local: health District for a permit.-to construct <br /> and/or install the work herein described. This application is madeiin compliance with San Joaquin ' <br /> County Ordinance..No:� 1862rand-,-the�LRul ioan <br /> Regula tions`of the San Joaquin Local Health- District. <br /> JOB ADDRESS/LOCATION ` _ .:/ o . W io a Qmpj1,or ,.CENSUS TRACT � SK , <br /> Owner's .Namely'k * m j' V. .G�t�I ' = `r, ,: Phone <br /> Address City Sa 6i=0. i <br /> Contractor's `Name License e A 7 hone <br /> TYPE OF WORK (Check) : . NEW WELL/ / DEEPEN /% RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /Y/ PUMP REPAIR/ / PUMP REPLACEMENT /?. <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. .of Well Casing pp <br /> Domestic/public Driven Gauge of Casing w <br /> Irrigation Gravel Pack Depth of Grout.Seal.' 4O <br /> Other Rotary Type of Grout �j1 <br /> Other Other Inform%ation <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> State Work Done Z / c..r� 40 <br /> -- — <br /> PUMP REPAIR: / / State 'Work,Done ;; <br /> +ii <br /> ,DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <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 /> WELD DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best my knQ edge and belief: <br /> .y� <br /> 194 TITLE <br /> 4w� ' <br /> SIGN <br /> (DRAW PLOT PLAN ON EVERSE SIDE) _ <br /> 1.001, FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE .� <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATEID <br /> CALL FOR-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. t <br /> E H '1426 �_ _R - - _ �,. <br /> - ~' 4172 1M, <br />