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_ 1 <br /> SAN JOAQUIN LOCAL;REPLLTH DISTRICT <br /> �F,OR?OFPICE USE• 1601 E. Hazelton�Ave..,.'�Stocktan, Calif. <br /> Telephone:,:�J2U9) 66i_6781 �� �� <br /> APPLICATION FOR WELL CONSTRUCTIOPI''OR" PUMP PERMIT Permit No, �f <br /> THIS PERMIT EXPIRES 1 =YEAR 'rROM DATE,ti'SSUED `` Dat 'Flesued, S J <br /> .: <br /> (Cpmplete,In Triplicate) <br /> 6t66 ttuct <br /> Application is hereby made to the San JoaquT iapplicat n is�inac�e'� compl anGeal Health' ,a-pdriaftricttw th San Joaquin <br /> and/or� install-the. work. hereiu described.,.. _ P..p <br /> Cauutp :Or.d3nancev.Plo., ,1862 and- the-Rules and Regulations ;of. the;°S an•Joaqu�n*Local geagthjDistrict. <br /> ? 3�5 S_ Ol�Zt1E �y .T j�{D-US <br /> - , Ilt CENSUS'TRACT 2 <br /> JOB ADDRESS/.LOCATION ,.� <br /> iYCOIIe' c <br /> Owner°s Name .:.; <br /> Address a.. .. <br /> License # b Phone <br /> Contractor's Name <br /> te..... , <br /> � TPLI <br />"TYPE,OF.WORK (Check):- LEW DEEPEN" / T -RECONDITION <br /> INSTALLATION PUP REPAIR /� . ACEMEN <br /> PUMP �T N <br /> N <br /> Other L 7 N <br /> PIT PRIVYLA <br /> 1 DISTANCE TO, NEAREST: SEPTIC TANK SEWER LINECESSPOOL/SEEPAGE IT` OTHER <br /> IPIT DISPOSAL FIELD <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 <br /> Driven Gauge of .Casing. . <br /> - irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type .of Grout <br /> Other . Other Information► <br /> Disposal <br /> Geophysical Su�cface .Seal 'Installed B r <br /> PUMP INSTALLATION: Contractor H#P. , <br /> Type 'o£ Pump <br /> PUMP REPLACEMENT: / / State, Work Done , <br /> �� <br /> PUMP State Work Done <br /> ,REPAIR:: • -'� <br /> 'Approximate Depth <br /> S'7TRUCTION OF WELL: Well' Diameter <br /> Describe Material''and Procedure <br /> i 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`,wrork on a new..well, I will furnish the San Joaquin Local Health District <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.. . I WILL.,CALL.FOR,A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION.. : . -...• TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE-- <br /> FOR •PARTMENT USE ONLY. <br /> PRASE IATE a <br /> ! APPLICATION ACCEPTED'BY <br /> /T D. .. . D %� _ Zc� jms <br /> -.-e . <br /> ADDITIONAL CONMENTS.: <br /> PHASE II GROUT INSPECTION " pHA II' FINAL INSPECTION <br /> ON <br /> _ B - DATE <br /> DATE INSPECTI <br /> INSPECTION BY " . �" <br /> _ _. <br /> ti R 'R ILL96 Rpm. 1-74 - <br />