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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Sroci:c.��i;, Calif. <br /> Tolephone: (209) 466--678 . <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.R2-S 9QZ <br /> TMS PERMIT EXPIRES 1 YEAR FP,0M 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .JOB ADDRESS/LOCATION T4 ! ✓04 1'1P CENSUS TRACT <br /> Owner's Name <br /> D►rt Phone <br /> Address Al 9�0 City <br /> Contractor's .Name e�` m a� 4�p License # Phone ), <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /% RECONDITION /�/ DESTRUCTION /_ <br /> PUMP INSTALLATION / PUMP REPAIR REPLACEMENT /_7 <br /> Other /_7 <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout CL <br /> Other Other Information J <br /> __cc <br /> PUMP INSTALLATION: Contractor V� 1.x.1 0 <br /> Type of Pump j t,, r r ,C'. 06 v H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> WELL DRILLERS REPORT of the well and notify them before1puLting the well in use. The above <br /> information is true to the best of my knowland belief. <br /> �7 <br /> SIGNED `� "�/c IuL `1/ . J" <br /> (DRAW PLO P D E "' E SIDE) <br /> ` FOR UYARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY �— DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL I <br /> E H 1426 4/72 IM <br />