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SAN JOAQUIN LOCAL',' HEALTH DISTRICT <br /> FOA OFFICE USE: 1601 E. Hazelton Attie.;: Std&kton, Calif. <br /> Telephone: (209) 46667.8-1 <br /> APPLICATION FOR WELL CONSTRIiCTION OR PUMP PERMIT Permit No-7 <br /> THIS ,PERMIT EXPIRES. I -YM, FRWDATE ISSUED Date Issued <br /> _ (Complete In iTriplicate) <br /> Application is hexeby made to the San Joaquin,,Local •Health,;-�Disttict_for a-permit to..construct :. <br /> and/or>install -the work: herein described:-. .: This. applicat.i.on is made-. tn compliance with San Joaquin <br /> County Ordinance No .. 862 and the Rules and Regpulatiosgf Sart. Joaqufn Local,Realth;:District. <br /> JOB ADDRESS/LOCATi N <br /> CxNfius-ma- <br /> Owner's Name Phone' � 1 ' <br /> Address <br /> - City C <br /> . _ --•-..-„ 8"x=6 �'V o� <br /> Contractor's Name ,- } License # Phone3� <br /> TYPE-OF WORK (Check): . NEW WELL y7 .DEEPEN /- RECONDITION /-.7DESTRUCTION <br /> PUMP INSTALLATION / / •PUMP REPAIR /-7-PUMP REPLACEMENT � <br /> Other . <br /> . . /! -� -... <br /> .DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES .PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _oWaIOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL—' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> a, Industrial �- Cable Tool Did. of Well Excavation 71 °- <br /> Domestic/private- , Drilled ,Dia. of Well Casing _ • ; <br /> Domestic/public DrivenGauge of Casing.. i <br /> ri <br /> Irgation Gravel Pack .. Depth of Grout Seal <br /> CathodicProtection Rotary Type of Grout ' <br /> Disposal ` ._ Other r__._�_ .Other information C <br /> Geophysical `Surface Seal Installed By;..�Jyyt Ad N <br /> PUMP INSTALL�#TION: Contractor <br /> Type of Pump . k H.P. <br /> I <br /> PUMP REPLACEMENT:" / / State Work Done <br /> PUMP :REPAIR: . 17 .State Work Done <br /> PES:TRUCTION 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-re-gulating well construction: Within FIFTEEN DAYS: <br /> after completion of my work on,a new well, I will furnish the San Joaquin Local.-Health_Dis.triet. 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 knowledgeand belief. I WILD,' CALL FOR'-A GROUTINSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNED TITLE <br /> (DMH PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br />. ADDITIONAL COMMENTS: <br /> 'PHASE II GROUT INSPECTION PHASII/FINAL INSPECTION <br /> INSPECTION BY DATE " INSPECTION BY f ,,.� DATE <br /> i E 9 1426 Rev. 1-74 T-74 2M <br />