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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /APPLICATIONTOR <br /> 1.601. E. Hazelton!"Ave. 5 Stockto�i, Calif. <br /> Telephone:, - (209),;46'-6781 <br /> WELL CONSTRUCTION"OR PUMP PERMIT Permit No. 7 7 J <br /> THIS :PERMIT .EXPIRES, 1 ,YEAR:FROM<DATE ISSUED• ' Date Issued ? 3 7-2-- <br /> l " �- , ". E/t•Sn;4s (Complete In 'Triplicate) = ',0Z-r'= 2'Fe9 -f 7 <br /> Application_'is-rhereby made <to--the •San Joaquin:.Loca Health District -for3a permit to construct <br /> 4 and/or install the work herein described. This.application -is-made.,-in compliance with San :Joaquin <br /> County! Ordinance�No: ;1562^and��the,Rulesaand'Regulations'-o£';the: San Joaquin -Local'Health District. <br /> +° .S:.i.'i {�'I :Y;,.id.x'`.J Y "7�� 7t: *, � ,•aY•s S`�.�..1{;�.;;£ s� - -i �t V <br /> JOB ADDRESS/LOCATION Z. rl/( J its E -� � ar� eyzooWA gtACENSUSTRACT � <br /> ��4 IST' YFk:Tt 4" rTo ,.:a i:i .1 (A I3 <br /> �Owner'.s7.Nime`3 R� y� LTo~t"�'.r r� t"_ : •ar. 4 f.. .,ti t Phone.,.- <br /> - �]�`'J-3� 7- <br /> Address 0, City ('IfA41t w�_0 �^ <br /> Contractor's Names -� - p, 7,2 . License. ��� ��/ Phone <br /> TM TYPE OF WORK (Check) : NEW WELLDEEPEN '/_/ RECONDITION /4/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /moi N� <br />+ Other. <br /> DISTANCE TO NEAREST; SEPTIC TANKI SEWER LINES) PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Vii-} CESSPOOL/SEEPAGE PIT OTHER <br /> GINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / <br /> Domestic/private Drilled Dia. of Well Casing <br /> --- Domestic/piibiic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �0 C <br /> Other Rotary Type of Grout G <br /> Other ` `Other Inform"ation"� . <br /> PUMP INSTALLATION; Contractor el,. 1 ' <br /> Type of Pump t<,r H.P. <br /> PUMP REPLACEMENT: / / State Work• Done '", <br /> PUMP REPAIR: / / State Work Done <br /> PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure Io <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, I will furnish the San Joaquin Local Health District a <br /> k� WELt DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> I information is true to the bes& of my knowledge an belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN 0 REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY , <br /> PHASE I i <br /> APPLICATION ACCEPTED BY C.' DATES. <br /> ADDITIONAL COMMENTS:= C__j/3 <br /> ip <br /> PHASE II GROUT INSPECTION PHASLO-III/EIN41. INSPECTION <br /> INSPECTION BY - - DATE //-/,Y'? INSPECTION BY - DTE <br /> 4: CALL ,FOR A_GROUT.,INSPECTION rPRIOR sTO GROUTING AND FINAL INSPECTION. _ <br /> E H 1426 4/72 1M <br />