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461 <br /> " SAN JOAN UI'C1 LOCAL 11ZALTH DIS1it1C1` { <br /> FOE OFFICE USE: - 1.601 E. Hazelton Ave. , Stackton, Calif. <br /> r� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, y. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued P_ <br /> (Complete In Triplicate) . <br /> application is hereby made to`the San Joaquin Local. Health District for a permit ,to construct <br /> ind or install the work herein described. This application is made in compliance with San Joago4n , <br /> 3ounty Ordinance No. 1862 and the Rules and ulations�of' the San Joaquin Local Health District: <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone <br /> a� r <br /> Address A� � City <br /> Contractor's Name - zcense # hone <br /> i , <br /> -• �:_ _�, -w� ate.�� - .: �� -r , •,:r--, .. _...�.__. <br /> TYPE OF WORK (Check) : NEW WELL /_I' DEEPEN' / I RECONDITION / / DESTRUCTION f� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 4N_ <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL v f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI 0dDNS <br /> ndustrial Cable Tool Dia. of Well Excavation / e-,/o r <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation avel Pack Depth of Grout Seal ° j. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <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 J u Loc ealth District a <br />:WELL DRILLERS REPORT of the well and notify them before putting t e We1 in u . The bove <br /> information is true to the best of my.-knowledge and belief. I WI L_ FO T ECTTON <br /> PRIOR TO GROUTING AND A FINALAINSPECTIQ�1 r <br /> r j �, . .. . .r .'•C - 1 ' TITLE r { L <br /> SIGNED <br /> DRAW PI: T�PLAN ON REVERSE SI I: !' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' DATE 2 - j� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSRECTION BY DATE L <br /> , 3/76 k9K. <br />