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- SAN-I�JIOAQUIN LOCAL I-I 'ALTH DT <br /> STRICT <br /> rll <br /> FOR OFFICE USE:•r ~~ 16G1 E. Hazelton Ave. ; Stocktou., Calif. <br /> Telephone: (209) 466--675.1. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1/3--IS 7A <br /> I THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED ; Date Issued <br /> (Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local' Hea'lth District for a permit to construct l <br /> and/or install the workij�herein described. This.appl,ication is made in compliance with San- Joaquin E` <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health, District. it <br /> �$t3 2.. C-4-•tl� �' :_;,r�N � 7���: �`-X40--1� ;; <br /> JOB ADDRESS/LOCATION �k fi <br /> r. CENSUS TRACT <br /> Owner's Name44 1s Phone <br /> Address A Q City <br /> j <br /> Contractor"-s- Namee'S 7 <br /> License #,22?jQ5 Phone IZ;? r � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN FT RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTAtATION PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLC� <br /> CONSTRUCTION SPECIFICATIONS {" <br /> Industrial Cable Tool Dia. of Well Excavation al 49 • <br /> _ Domestic/private 4�-Vrilled Dia. of Well Casing 6 61 <br /> _4__ ITomestic/public —Driven Gauge of Caging — <br /> Irrigation <br /> asing _Irrigation , gavel Pack Depth of Grout Seal �jp � f� <br /> Other 4--Rotary Type of Grout — ZI <br /> Other Other Information <br /> P5MP_INSTALLATION: Contractor <br /> . T.� ' H.P. <br /> pe of Pum / `i <br /> � <br /> FJMP <br /> REPLACEMENT: <br /> /IIS/ State Work Done <br /> -�< 11 <br /> PUriP 'REPAIR: A'/ State Work Done <br /> ,pESTRUTION_ OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />„I hereby agree to complyi�with all laws and regulations of the San Joaquin Local Health District i <br /> atd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />'aftex= 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 d <br /> informatiM is true to �� best of my knowledge and belief. <br /> SIGNED ' ! ` <br /> TITLE <br /> �4 (DRA PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPAR 'NT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . ro <br /> PHASE�TI GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> CALL FOR A GROUT_INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 � 7 <br /> �� -� �� 4/72 <br />