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s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton. Ave.:, `Stoclston., Calif. <br /> Telephone (209) 466-6781 <br /> cAIPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> V THIS PERMIT EXPIRES l YEAR, FROM DATE ISSUED Date Issued <br /> (Complete Iii, Triplicate) 2-0-5—Ory--0 <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 No 1862 and .the Rules and Regiilations of the San Joaquin Local Health District. <br /> �". <br /> 15`7 II� <br /> JOB ADDRESS/LOCATION �} CENSUS TRACTI'S` `�q <br /> Owners Name Phone <br /> Address p IS, City <br /> Contractor's Name 41 Ado License #lao l Phone f 3£r--7S2 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/% RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? � <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I(� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ _ t1 _ <br /> Domestic/public Driven Gauge of Casingr_c� <br /> �_ Irrigation Gravel Pack Depth of Grout Seal <br /> ,� /tea ��`� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �- M <br /> Type of Pump H.P. <br /> PUMP: REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done ~ <br /> ,DESTRUCTION OF WELL: Well Diameter /V Approximate Depth /0 <br /> Describe Material and Procedure _ C-'N{ A n)j <br /> & <br /> W z[. 13e l�69T/?a D W 6 DTA-FAEP 4?X t� —_ <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 /> 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /. <br /> APPLICATION ACCEPTED BY DATE /W�2 <br /> ADDITIONAL COMMENTS: „ <br /> PHASE II PIZT INSPECTIONPHAS SII / NAL INSPECTION <br /> INSPECTION BY DATES -191,783-? }_ ,�1,ll • <br /> CALL FOR A GROUT INSPEC.TION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M C,,0 <br />