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SAN JOAQUIN LOCAL HEALTH ;DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , {Sfoctitoz, Calif. } <br /> 1 <br /> Telephone: (203) 4666781 <br /> .0114- APPLICATION FOR WELL CONSTRUCTION. OR PUMP PEIUMIT Permit No. <br /> THIS PERMIT EXPIRES 'l YEAR;FROM:DATE ISSUED Date'`Issuedk <br /> J.i (Complete In"Triplic-ate`) ,�F C� 447 <br /> Applicatipn,:is-Thereby:madejto the.�San Joaquin. Local Health Districtifor a,permit to 0, <br /> struct <br /> and/or install the work herein described. This application is-`made,in -compliance with San Joaquin <br /> County_.Ordinance No e1862 and th6oRule 9',and Regul tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ENSUS TRACT 'J~ 3 i <br /> �'nn'rin si an of ffoodb-j a gp Road jus_ ' i?�. ,tra6k <br /> i.Y]-Ct.1V .. - a ^� <br /> �SL� _� - <br /> . r <br /> Owner! ,, . Y: - <br /> P <br /> ' �° :.o �`- � • .� �••, ,.< _�.,�..� t hone <br /> Address gst n IT ; ��a r qua . — - City, _ <br /> Contractor's NameJnnq1jITap License # p.77-P00 Phone iyq=471 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR I / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER D4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation loll <br /> Domestic./private Drilled Dia. of Well `Casing loll <br /> Domestic/public Driven Gauge of Casing "" 10 _ <br /> Irrigation Gravel Pack Depth of=Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> E 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 before putting the well in use. The above <br /> information is true to the best of my knowledge and b lief. <br /> SIGNED TITLE , Ban nnirQr <br /> (DRAW IFLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> ke-) <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> _ PHASE 11 GROUT INSPECTION P S I /FINAL IN PECT ON <br /> INSPECTION-BY DATE INSPECTION Br> ' f' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 (r4/72 IM <br />