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SAN JOAQUIN LOCAL ?IE til`DISTRICT <br /> F@R -OFN` CE USE: 1.601 E. Hazelton A.ve. Srockto, Calif. <br /> Telephone: (20e;). 466-•61d1 <br /> k APPLICATION FOR WELL:CONSTROC'TIUL <br /> ON OR PP PERMIT Permit No. 7L. ? 0 b <br /> THIS PERMIT EXPIRES 1 YEAR FROP, D�1T :ISSUED : Date Issued 7-/3,-7 <br /> } (Complete In Triplicate.) <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 incompliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District.-- <br /> JOB <br /> istrict:JOB ADDRESS/LOCATION <br /> GEN SUS TRACT <br /> Owner's Name l� - Phone7�3- ��®�1 <br /> Addressy <br /> Cit <br /> Contractor's Name ' License � aL Phonel�j7-� <br /> # TYPE 40F WORK (Check): NEW WELL e•. _,_,_._. .._._,___. <br /> . DEEPEN '/ / RECONDITION /-7 DESTRUCTION /7 <br /> N. --;_PUMP:-INSTELATION.pX-7:�P-W-RS�PA-IR-/-/,PUMP:.REPLACEMENT=.17-, <br /> . .Other <br /> . <br /> DISTANCE; TO NEAREST: SEPTIC TANK'` SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSALFIELDCESSPOOL/SEEPAGE PIT ,' OTHER <br /> C: INTENDED USE TYPE OF WELL :,CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool4 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation,-. Gravel Pack Depth, of, Grout Seal <br /> Other >< Rotary i Type of Grout ' <br /> Other Other Information <br /> *411 <br /> PUMP INSTALLATION: 'Contractor:' i s" ��,. I;� <br /> k Type of Pump a H.P <br /> PUMP REPLACEMENT: <br /> State. :Work Done <br /> �j7- <br /> OT- 14 -ip/-x` 0IRA ME <br /> PUMP REPAIR: / ./ State Work Done cw pt-J <br /> )7ESTRUCTION:OF WELL:._ Well Diameter A <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, Twill furnish theSan Joaquin Local Health District a <br />, ".WELL DRILLERS REPORT he well and notify them�before­puttiIng the well in-use. The above <br /> information is tru s a kno dge and".belief.. , <br />' SIGNED . _ TITLE , <br /> (DRAW PLOT PLAN ON REVERSE-SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I lla ? <br /> „�/ <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE•II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172. 1M <br />