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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazelton Ave. , Stoclho' n, Calif. <br /> Telephone: (209) 466-6781 , <br /> f APPLICATION FOR.WE.LL'CONSTRUCTIONFOR PUMP PERMIT Permit No. <br /> THIS `PERMIT EXPTRES 'I YEAR FROM DATE ISSUED <br /> Date Issued <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 in compliance with San Joaquin' <br /> County Ordinance ,N6. 1862 and the `Rules and' Regulations of 'the San Joaquin Local Health District. <br /> ... 7 . �r. <br /> JOB ADDRESS/LOCATION �, C IIA lib e CENStJS� TRACT r <br /> Owner's- Name '� s � s, � � � <br /> Phone ! _ C4 <br /> Address ,f <br /> - City .70 i <br /> Contractor's Name -. � -.., 5 License # { <br /> &2 3 Phone 1714� <br /> TYPE OF WORK (Chee-k):'NEW MELL <br /> .T - v... <br /> DEEPEN /-77- =RECONDITION /_� `DESTRUCTION /�- <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other /% PUMP REPLACEMENT /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LIMES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS ; <br /> D'C, Cable Tool Dia, of Well Excavation / ' <br /> Domestic/private Drilled Dia. of Well Casing __ _ <br /> _ <br /> IrrigaDomesttion <br /> Driven Gauge of Casing G. <br /> -_( Irrigation Gravel Pack Depth of Grout Seal J "— 66, <br />-�---- Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor y � <br /> Type of Pump i <br /> &.P. <br /> PUMP REPLACEMENT: / / State Work.Done ; <br /> F 4 <br /> PUMP REPAIR: <br /> /7/ State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the an 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 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, i <br />"SIGNED <br /> TITLE <br /> DEPA <br /> (DRAW P-.OT PLAN ON REVERSE SIDE " <br />'RASE I R RTMENT`USE ONLY <br />►PPLICATION ACCEPTED BY . DATE �dZ -����� <br />►DDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III FINAL a-NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -//' 7-7 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - <br /> 7/72 1M <br />