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VSAN JOAQUI3 LOCAL HEALTH DISTRICT <br /> DOR OFFICE USE: 1601 E. Hazelton Ave. , StocktoL, Calif. <br /> 16z <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L 6�3 <br /> qy( <br /> THIS PERMIT EXPIRES, 1 YEA�L FROM DATETSSUED Date Issued 7 .5-7 v <br /> (Complete' In Triplapate) <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/LOCATION0ZZ /,q �j.�j��� ����, CENSUS TRACT <br /> Owner's Name s -t'/G A .r" ! �� Phone 'y l <br /> Address - City7cxc �z-�. <br /> Contractor's Name ISLE„ G License ipO�jf Phone <br /> 1$ } <br /> TYPE OF WORK (Check) NEW WELL / DEEPEN`'/_7 'RECONDITION f7 DESTRUCTION /-]' <br /> PUMP INSTALLATION / i �PUMP REPAIR/—/ PUMP REPLACEMENT /-7 <br /> Other <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 Gaug6 of Casing `s / <br /> Irrigation Gravel Pack Depth of Grout Seal '� Y <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 /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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 o e well and notify them before putting the well in use. The above <br /> information is true o thelb my knowle ge and belief. <br /> SIGNED TITLE _ <br /> RAW <br /> PLJOT PLAN ON ,)REVERSE SIDE <br /> ZODEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY(j� DATE 07 L-- <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT„INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ D� INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />