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SAN JOAQUIN LOCAL'HEALTH DISTRICT � s <br /> FOPirOFFICE USE: 1601 E. Hazelton"'Ave. ,vStackio y„,Calif. ;:-17' <br /> Telephone-.fY, (209) 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit .No. <br /> THIS. PERMIT tEXPIRES 1 ..YEAR FROM, DAT E,ISSUED't r ' <br /> Date Issued <br /> ..(Complete .In. Triplicate) >. <br /> Application is hereby made to the San Joaquin.Local-=Health'-Diitrict- fcor 'e permit• to .cotCstiruct` . . <br /> and/or install the work herein described: •,.This `applizatio t is.;made; in ooinplisi�ce- with�Sala Joaquin <br /> County Ordinance No. ;l$62 and the Rules. and 4tegulations of"the SangJoaquin:Local, Health' Diiiiict. 1 <br /> JOB ADDRESS/LOCATIONA.r `: w_ CENSUS`TRACT` <br /> Owner's Name Phone°: <br /> -. µ . <br /> AddressL414; ,a..,.,.�. .�...�..... .... _ _�:.. <br /> Cita,., . .. . <br /> Contractor's Name ��sfa� <br /> License -#' d Phone ay <br /> WELL /�T E P;W1 '/_-7—R <br /> TYPE OF WORK (Check): NEW} �. ,___ECONDITION / <br /> _ — �STRUCTION /7 "1 <br /> PUMP. INSTALLATION / / PUMP REPAIR./ 7 PUMP •'REPLACEMENT. r f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK. ,u SEWER LINES. FIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSFOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL ' <br /> INTENDED .USE <br /> „ TYPE OF WELL ''CONSTRUCTION SPECIFICATIONS --4 <br /> -Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ILQ� f <br /> Domestic/public a Driven Gauge of Casing, k <br /> Irrigation Gravel Pack '4 Depth of'Grout Seal 5 ' <br /> Cathodic Protection RotaType <br /> rY �� - of 'Gro'u' t • : mil <br /> Disposal Other Other' Information a .. ... <br /> Geophysical Surface Seas. Installed B : <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> x E <br /> PUMP .RRETPAIR; - /-7 State Work Done- <br /> .. -- <br /> ESTRUCTTON 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, 1 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � . � _ �. .. . <br /> APPLICATION ACCEPTED BYC - ... . DATE �_j �y <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTI N PHASE III FINAL INSPECTION..: ,j "'� <br /> INSPECTION BY DATE ° INSPECTION- BY - DATE <br />! E H 1426 Rev. 1-74 1 <br /> -- - --. 1-74 2M s <br />