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~ SAN .JOAQUIN LOCAL HFALTH DISTRICT � r <br /> FOR OFFICE USE: 1601 E. Hazel to-ri;.Ave-.-;,1`:Stockt6v,, Calif. <br /> k� Telephone': ....•(209).:466-6781 : <br /> PLICATION FOR WELL CONSTRUCTION`•OR PUMP PERMIT Permit No. <br /> T <br /> THIS PERMIT''EXPIRES.= 1'.YEARS F''ROM.DATE- ISSUED -Date Issued <br /> (Complete =ln°Triplicate) <br /> Application'.,,itaherebyr,:nadei.to the San;!Joaquin'Local Health District; for a permit ,t& construct <br /> and/or install the work herein described. This--application- is madein compliance with San Joaquin <br /> County .Ordinance}No:•,1862'fandf,therRu.le�s`sand Regulatioi►s'�of`the San Joaquin Local Health District. <br /> - i . -�rac �>s.1 yI# .-5 31•Lt1'a1�?�y`odQ�<<Y:k�: <br /> JOB ADDRESS/LOCATION c ° ,� ' -.CENSUS• TRACT` , <br /> .��'� <br /> Owner!s,,Nanie ll ZI Cx/�4t << 10 7;P o . .1", +; Phone <br /> E _ <br /> CAddress City x. <br /> Contractor's Name B �,,,� License # /y 3 7�_ Phone �/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION /7 DESTRUCTION /— " <br /> k PUMP INSTALLATION / / PULP REPAIR Jy(/ PUMP REPLACEMENT /7 <br /> Other / / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERfLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD, i r CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well/Excavation ,,AA <br /> * Domestic/private Drilled Dia. of Well Casing ov,Q <br /> Domestic/public. D-tiven Gauge of Casing <br /> � <br /> Irrigation ,__GravelrPack_ -Depth. of.-,Grout, Seal, _ <br /> r � Other <br /> Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Y ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> KIM REPAIR. /.../ State Work Done L,- , <br /> sd <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 /> j 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 /> SIGNED TITLE 'L <br /> W MOT PLAN ON REVERSE SIDE) <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> 7 PHASE II GRO SP CT PHASE II/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE2- If 2Q <br /> CALL FOR A GROUT, INSPECTION .PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 4/72 <br />