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SAN JOAQUIN LOCAL. HEALTH�DI-STRICT 12/ -7aT I i: Y <br /> FOk OFFICE USE 1601 E. .Hazelton Ave. ,I%.Stockeon, Calif. <br /> Telephone:.. _(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> - } + THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �. <br /> (Complete, In Triplicate) Qp,s'_ Uka-2f ' <br /> Appli,'cation'`is Aeteby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applications made in compliance with San Joaquin.' <br /> County Ordinance No. 1862 a6d .the Rules and Regulations of he San Joaquin Local Health D AStrict. k <br /> JOB ADDRESS/LOCATION 7y- -+1- .A 4 CENSUS TRACT 7�t <br /> Owner's Name _2 'T d,L: Ph <br /> � � ! �� one fir. <br /> Address �� r �`�41 �, :! <br /> . _ city <br /> Contractor's Name S <br /> � � .License ,/��,3;,a+�� Phone-7'V�/3 <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /�/ ,,;,,RECONDITION /-7 DESTRUCTION /-7 � <br /> 'PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD c� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED USE` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4-- Cable Tool Dia, of Well Excavation - /to <br /> Domestic/private <br /> Domestic/public Drilled Dia. of Well Casing <br /> - <br /> s; Driven Gauge of Casing <br />` ,Irrigation ~"}--Gravel;Pack 'F'( >�'Depth of rout Seal <br /> Cathodic" Pr <br /> otection Rotary '�T e' of ut <br />, a <br /> _____Disposal `..Other yP <br /> Other In o mation <br /> Geophysica3 - - ""-� Surf e <br /> al Instal ed B <br /> PUMP INSTALLATION: Contractor. ]] Viz , /rY <br /> Type of.- 't'imp j�fv - V "H <br />•'UMP,REPLACEMENT: ::� . .._. .. <br /> _..._ <br /> / / State Wor D e <br />'UMP .REPAIR: / / State-Wor Done <br /> iES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth ' . <br /> Describe Material and Procedur J <br /> hereby agree to comply with all .lawsand regulations bt the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> Lfter completion of my work on a new well, I will furnish the San Joaquin Local Health District r <br /> TELL DRILLERS REPORT of ,the well and notify them before putting the.-well in use. The above <br />.reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTI�GA FINAL INSPECTION. <br /> IGNED <br /> TITLE � 3 ?.St t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �— <br /> t: FOR DEPARTMENT USE ONLY <br />'HASE I ; <br />.PPLICATION ACCEPTED BY, ATE (�� <br /> DDITIONAL COMMENTS: <br /> :PHASE II GROUT INSPECT.IO INSPECTION <br /> NSPECTION BY DATE v INSPECTION DATE <br /> E H`1426 Rev. 1-74 �l/0 / (NY!"� � j�/ � - "�77 2M <br />