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SAN JOAQUIN LOCAL HEALTH DISTRICT � � n <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stobkton, Calif, KLP- "0 <br /> � <br /> 0 5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. 7 z--.3 2-w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9t?-1- 7 7-- <br /> (Complete In Triplicate) <br /> Application is hereb 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 CENSUS TRACT <br /> 'S <br /> Owner's Name Phone <br /> Address City /Ne <br /> Contractor's Name fl10/OF._C.- License # G] GG2 Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /- / RECONDITION /_/ DESTRUCTION /-7, <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT '/_T r' <br /> Other <br /> DISTANCE TO`NEARESTi SEPTIC 7ANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. VIELD CESSPOOL/SEEPAGE PIT OTHER ✓ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial--__..y �_-Cable Too] Dia, of Well Excavation �., <br /> Domestic/private Drilled Dia, of Well Casing ih <br /> Domestic/public Driven': Gauge of Casing <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> Other <br /> Rotaryr. Type of Grout <br /> Other Other Information qc <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r, <br /> PUMP REPLACEMENT: / / State Work Done A <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 before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDJ i <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �* <br /> L+ _ FOR DEPARTMENT USE ONLY f <br /> PHASE I � f..r <br /> APPLICATION ACCEPTED BY -- . .DATE <br /> z . . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSF CTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. { <br /> E H 1426 7/72 lM f <br />