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� Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AOR OFFICE USE: 1601 E. Hazelton Ave. , Stackton , . Calif. <br /> l Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 37 /3 V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ©& <br /> Local. Health District for a permit to construct <br /> Application -is hereby made to the San Joaquin <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 /> '' -gi ! p ,�. CENSUS TRACT I <br /> :JOB ADDRESS/LOCAT7Oi3 " <br /> Phone 13C=s f <br /> Owner's Name <br /> { <br /> city <br /> Address .' <br /> License # Phone I <br /> Contractor's Name <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /7/. DEEPEN /7 RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/ /� PUMP REPLACEMENT49 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EEPAGE IT OTHER , "�? <br /> INTENDED USE PE OF ELL CONSTRU ION SPECIFICATIONS <br /> Cable Tool w, Dia. of Well Excavation <br /> ' Industrial ' ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f Gravel Pack ,�.. Depth of Grout Seal <br /> Other ' � Rotary Type of Grout . <br /> Other r Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , H.P. +- ` <br /> PUMP REPLACEMENT: / / State Work Done ,6c. sE. •` - <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth'___,, <br /> Describe Material and Procedure <br /> j ` f <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 -FIFTEE& DAYS <br /> ll furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, I wi <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information. i true to the t of my knowledge and belief. <br /> SIGNED, <br /> IGNE - - T <br /> TITLE <br /> D <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /? � DATE / ~� <br /> APPLICATION ACCEPTED BY ` <br /> ADDITIONAL COMMENTS: %� , <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPE TION <br /> INSPECTION BY _ �, DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING ^'FINAL. INSPECTION. % 4/72 1M Nom. <br /> E H 1426 a/u <br />