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W SAN JOAQUIN LOCAL.-HEALTH DISTRICT T <br /> FORrOFFICE USE: 1601 E. Hazelton',Ave:, ,Stdc'kton, Calif. <br /> Telephone:.-(209) 466=6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. �,s2­5_27JO <br /> ' i # � : 1'V,yi.-. . 'y 1 . E.j <br /> THIS PERMIT ,EXPIRES 1.,,...XLARFROjM DATE ISSUED Date Issued <br /> a yii �. (Complete:"�L�,{.Tripli{'ate) ' * -� <br /> Application is hereby made tolthe San Joaquin..Local-Health District for a parmit to construct 111' <br />; and/or install the worts herein described. This ,application .is made in compliance with San Joaquinf <br /> County Ordinance No.-J862 and, the Rules and ..Regulations.of the San Joaquin Local Health District. <br /> JOB ADDRESS./LOCATION ,. <br /> . , _ `t.t . "G.T '- . CENSUS TRACT <br /> Owner's Name 4—Ai1_i L L u Em ' . <br /> Phone <br /> s city_ ..mom �;. . .._ �._ . _ ... .� .. �. <br /> Esc ala <br /> Address=' .� <br /> Contractor's..Name° , ,Q, d,,, ,r J -- License #c>?7- 49,1,0 Phone <br /> TYPE OF WORR'I (Check).:r-NEW-WEI;L-"/7-_ I DEEPEN- /:�7- -RECONDITION S'/77-- DESTRUCTION <br /> PIMP INSTALLATION /7—//- PUMP REPAIR /�—/ °7 PUMP RErLACEMEjaT <br /> a . <br /> + � Qther'l/ 1/,1,Fr�� �„475 L <br /> . 1.1 <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - ' OTHER <br /> PROPERTY LINE - PRIVATE DQMESTIC 'WELL-'" -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL f CONSTRUCTION SPECIFICATIONS <br /> r Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation' 1 Gravel Pack Depth of Grout Seal j <br /> ' Cathodic Protection A Rotary Type of Grout' <br /> Disposal 1 Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION. Contractor <br /> : Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> C ` <br /> State Work Done <br />"PtTMP7REPAIRc '- - -� == <br /> �/ Sate 'Work Done <br /> UCTIOOF WELL: Well Diameter <br /> �ES•TRN L•--�• - . Approximate Depth <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 regulA.iitg well construction. Within FIFTEEN DAYS <br /> after completion of my work ori a new well, 'I will_furiish 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 af. my.knowledge, and-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN,G,AND A F AL INSPECTION:, i <br /> SIGNED <br /> TITLE ,. <br /> (DRAW PLOT -PLAN ON REVERSE SIDE <br /> L „FOR I1E�TMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I TAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY DATE - ~ ' <br /> ,R H 1426 Rev. 1-74 1-74 2M <br />