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SAN JOAQUIN -LOCAL,-REALTH DISTRICT <br /> TOUSE: 1601 E. Hazelton.Ave , 'Stioc[cton9 Calif. <br /> Telephone:F 609) A66-678.j. <br /> APPLICATION FOR WELL CONSTRUCTI,ON'OR '].'tfMP PERMIT Permit No. 7LI- 2 9L1c? <br /> i <br /> �,-Gi{�. ;��•.fb "A�i6 ... .�` d .i'd�-t. `Y ',,. 1 .. i •'.. .': ., c. . � <br /> THIS PERMITXP.IRE5; ,1-"YEAR FItbM DATE' iSSUD " =Date Issued•'` <br /> .= (Complete:.In_^.Triplicate)`. �; <br /> i Application is hereby made to the San Joaquin -Lbca tealth.District"1b ar"perm t=. to ,construct. <br /> and/orv,ins:tal.l the.work herein described.v-..;This app3icatior $s' made 44v-ltompliante with San'.Joaquin <br /> County Ordinance No ;1$$2 aiid, the Rules,land Regulations .of ch '- S"an ,Joeq-uirrgLoeal:' Health N District; <br /> ;JOB ADDRESS/LOCATION 4i = I 1k '° CENSUS TRACT.t <br /> to. <br /> Owner's Name -,-Phone <br /> Address-:&Q <br /> Contractor's Name 0AWLicense I Phone Fsf­ <br /> 'YPE OF' WORK (Check). NEW'WELL k_/7 Di�EP�a / RECONDITION /" ,.•- <br /> f .. .. `7"DESTRUCTION f7 <br /> t PUMP'. INSTALLATION / /•:'PUMP REPAIR / T. . Ri�I+H' RE LAC J <br /> { Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT. PRIVY . - _. <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE.PIT . OTHER <br /> -PROPERTY LINE ?RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED .USE TYPE OF WELL $ b CONSTRUCTION SPECIFICATIONS <br /> Industrial Y _ Cable Tool Dia. of Well Excavation <br /> Domestic/private' Drilled. 1- Dia. of Well Casing' <br /> Domestic/public Driven Gauge of,'Casing <br /> Irrigation Gravei'Pack Depth of Grout Seal. ' <br /> "Cathodic Protection Rotary: Type of Grout <br /> Disposal Other Other Information . <br /> Geophysicallle < <br /> Surface Seal insta� d B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP:IREPAIR: /7 1 State Work Done... ; <br /> PES;RUCTION OF WELL: Well FDiameter 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 /> 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. IWILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. - <br /> ` SIGNEDTITLE` <br /> r F {DRAW PLOT PLAN ON REVERSE SIDE <br /> :. <br /> ;FOR DEPARTMENT USE ONLY <br /> PHASE I : 7. <br /> APPLICATION ACCEPTED BY k DATE � � <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT� INSPECTION PHAS III FINAL INSPECTIOJI <br /> INSPECTION BY `i DATE INSPECTION- BY DATE 3l <br /> irye« �' � ... �.....K..•_..... - .•� .- �-K, :._ T_,,._...,.. �.` _ ..... ., .._ ,r. "` ��"". <br /> H S 1426 Rev. 1-74 - _ a, 1-74 2M '.�'. <br />