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M e 7-e.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 11601 E. Hazelton Avev;� Stackton, Calif. <br /> Telephone: M (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti-37,5 GGrJ <br /> t_ <br /> U THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J1;00- A16WIL W/l 4.( E SUS TRACT <br /> Owner's Name �(f}ZL4&tA Phone <br /> Address •'2�5��1�' . &),eD l� �c=fi G � '�i�f City <br /> Contractor's NameZA4 License #� U&3 Phone-Z-It3< / <br /> i <br /> TYPE OF WORK (Check) : NEW WELLIjK DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / 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 /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ��� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation k1 Gravel Gravel Pack Depth of Grout Seal <br /> Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Information ��.mfJt� <br /> Geophysical Surface Seal Installe <br /> PLV INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 thewellin use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A UNAL INS CT10 . <br /> SIGNED -LA& ITLE <br /> DRAW &OT PL ON REVE E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I /F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> rr 3/76 2M <br /> E H 1426 Rev. 1-74 <br />