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- SAN JOA UIN LOCALT.MA31TH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazeltoxi Ave. `Stocictoki:, Calif.�7a7 <br /> Telephone�:'. '(209)-?,466-678 3 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 <br /> THIS PERMIT. EXPIRES IL YEAR'FROM�,ATE 'ISSUED Date Issued 2-�/-7 L <br /> ..;: ,(Complete `In', Triplicate) <br /> Application..is�hereby,:made:to ',,theiSanIJoaquin_ Local. HealtYI District for a permit to construct <br /> and/or install the work herein described. This:applicatil is -made in compliance with. San Joaquin ! <br /> County Ordinance No:g1862 and,.the, Rules and,,Regulations- ofj'.the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION 932 �Paloma _ CENSUS TRACT_ <br /> Owner!s:.Name�! � � . t , . . . Johigr.R..�„Burke � s�{' i < ; rr..��=r Phone 477 1448 } <br /> Address 9321Paloma City Stocktom. <br /> Y .. --t License #272 303 Phone477 1858 <br /> Contractor s Name Je A. Ihalhamer Coo. <br /> TYPE OF WORK (Check) : NEW WELL /ice/ DEEPEN'/ / RECONDITION / / DESTRUCTION /7 <br /> --»- - -� <br /> 4i—PUMP"'INSTALLATION // PUMP REPAIR-'/ / PUMP REPLACEMENT /7 <br /> i Other / / <br /> DISTANCE TO NEAREST: SEPTIG:TTANK ft- SEWER LINES moi • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,_ _ CES.SPO.OL[SFEP.AGE-PIT., OTHER <br /> INTENDED USE :_TYPE OF�WELL CONSTRUCTION SPECIFICATIONS <br /> F Industrial Cable Tool Dia. of Well Excavation inc <br /> Domestic/private s. Drilled Dia. of Well Casing inc <br /> -0109 <br /> Domestic/public `� Driven ;' Gauge �of'Casing <br /> �f Irrigation. 1 Gravel Pack 'Depth...of Grout Seal 50 ft. <br /> ' Other 1 - Rotary Type of Grout Cement <br /> Other other Information ' <br /> PUMP 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 /f _. Approximate Depth <br /> ry/ _/v Describe Material and Procedure �4-• � -+�� <br /> I hereby agree to comply w th /all laws and egulations 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 nevr'well;�"I -gill 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 /> Sinformation is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> TITLE - Cu -cci <br /> {DRAW PLOT PLAN ON REVERSE. SIDE) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 I DATE -- l — `Z . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS• <br /> PHAINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTIONBY ' DATE - z� INSPECTION BY DATE -- ?�--72- <br /> CALL FORA NyPECq ION_PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />