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9 SAN JOAQUIN LOCAL ;HEALTH DISTRICT <br /> FO ' <br /> A+'OFFICE USE: 1601 E. Haxel'ton''Ave. ; TSiockton, Calif. {' <br /> Telephone: (-X209) 466"6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� ' 3,2121 <br /> THIS PERMIT .EXPIRES; I,-YEAR,-FRaM--DATE ISSUED Date Issued <br /> (Comp�ete:,in Triplicate) <br /> Applica ion is hereby made to the San Joaquin. Locaj,,Realth District for a permit to construct E <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 -Regulationsa.of.the San Joaquin Local-Health District.. <br /> JOB ADDRESS/LOCATION - ;1 7r L 2. ¢ CENSUS TRACT <br /> Owner's Name a �C' 0 S, e Phone <br /> Addressir <br /> City <br /> Contractor's Name -.- :�14 License # Phone <br /> i <br /> TYPE- OF WORK (Check) : NEW WELL '/ DEEPEN /� RECONDITION /—T DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUN? REPLACEMENT J <br /> Other ET <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE P PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable.Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia;-of Well Casing V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal `\vU <br /> Cathodic Protection Rotary _Type, -of Grout <br /> Disposal Other t Other- Information <br /> r Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ! . <br /> o Type of Pump H.P. .1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP �REPAIR: /_7 State Work Done ;Ih <br /> ES-TRUCTION OF WELL: Well Diameter �-ii Approximate Depth <br /> Describe Material and Procedure <br /> — <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. . I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING ANJX A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA Tvi/F NAL INSPECTION <br /> INSPECTION BY DATE l INSPECTION BY DATE Z 7 <br /> ��. 1M1E H 1426 Rev. 1-74 1-74 2M C <br />