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Z) SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> 4.,. <br /> XOT USE: 1601 E. Hazelton. Ave. , Stoc�toz:, Calif- T3_ oII <br /> , .�"Y• Telephone: (209) 4'66-6781 S� I <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. - -- -- { <br /> THIS PERMIT EXPIRES I.YEAR FROM DATE.'ISSUED- Date Issued S <br /> (Complete In Triplicate) <br /> Application' is .hereby madeito the 'SaaquThis�applicationDistmadeca Health �inrcompliance-a permit twithnSan Joaquin { <br /> and/or install the work herein described. <br /> County Ordinance�No:-11862 andr'the- Rules`>and Regula <br /> tions�af''the San Joaquin Local Health District. <br /> T W T ' CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> cp„ :n • :.G.�nitrur: r,.Rs :s:,��. .. r- • Phone' 3 <br /> Owner!s- NAme"r- o- n 11. � <br /> City <br /> Address d _. <br /> 1_1�.qq�� <br /> �y f <br /> License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /�/ RECONDITION / P DESTRUCTION <br /> / _7 ✓I <br /> PUMP INSTALLATION / / PUMP REPAIR / i <br /> Other / <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY SEEPAGE PIT OTHER v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Drilled <br /> Domestic/privateDriven Gauge of' Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal . <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> t <br /> PUMP REPLACEMENT: /;//State Work Done <br /> PUMP REPAIR; / / State Work Done <br /> _DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> lFh <br /> I hereby agree to. comply with all laws and regulatan o elleLocal aDistrict <br /> constructi.on. WithinFIFTEENDAYS <br /> and the State of California pertaining to or regulating <br /> well, I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new <br /> notify them before putting the well in use. The above <br /> WELL DRILLERS REPORT of the well and <br /> informati n is tr to the est of my knowledge and belief. <br /> ° Y .,� TITLE ! o <br /> SIGNED �_ 16 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: l <br /> PHASE II RO N I N �- %&IFINNAL INSPECTION <br /> INSPECTION BDATE �• -? <br /> INSPECTION BY DATE „.� ...- <br /> CALL FOR A GROUT INSPECTION PRIOR-TO GROUTINGANb FINAL-INSPECTION..., 4/72 1M <br /> E H 1426 = 31 <br /> K -- <br />