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SAN JOAQUIN LOCAL :11EALTU DISTRICT <br /> FWOFFICE USE: 1601 E. Hazelton -Ave. ," S�o&66n', Calif. <br /> Telephone: (209.) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5_- 416y0 J <br /> THIS "PERMIT EXPIRES 1 YEARrFROM'DATE ISSUED Date Issued $-dZ/-7,f_ <br /> (Complete In. Tr plicete) 3 <br /> Appiic�ition i's her* made to the San Joaquin: Local Health Diatritt 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 -Regu.14 .ons.of the San Joaquin Local Health District. � <br /> i <br /> JOB ADDRESS/LOCATION. V CENSUS TRACT <br /> Owner 9 s Phone y' <br /> Address City ' Cil'T <br /> Contractor l e Name LicAnse # ,Z Phon 3. . <br /> TYPE OF WORK -{Check): NEW WELL "/-7 DEEPEN /- RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR Y1 PUMP REPLACEMENT /7 <br /> Other <br /> �l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ( " <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE7IOMEST.IC-WELL "'- PUBLIC"D'OMESTIC WELL (� <br /> INTENDED USE TYPE OF WELL r `� �_ . X CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.. of Well, Excavation ] <br /> Domestic/private Drilled . "' t1 -" Dia. o€ We11`Casing f <br /> Domestic/public Driven , J' jtauge .of,Casing " _F + <br /> Irrigation g Gravel Pack" (,Depth of ' <br /> Grout Seal.. • <br /> Cathodic Protection Rotiry r Type .of Grout. f <br /> Disposal Other Other Information fi { <br /> Geophysical <br /> PUMP INSTALLATION: Contractor • _ � . _i�7;7i7 --- 5 <br /> Type of Pump ' ti. H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' ✓ , <br /> PUMP 1REPAIR: Stat Work Done"' <br /> --_- �rApproxiinate-Depth E&TRUCTION OF WELL: Well Di et; <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,Joaquiii Local Health District a <br /> WELL DRILLERS REPORT of the well�and notify them Vefore\putti.ng the.-well in.use.. The above <br /> information isruej, o the best. of my.knowledge and belief. I WILT, CALL FOR A"GROUT INSPECTION 1 <br /> PRIOR TO GROU G A FINAL INSPECTION. � <br /> SIGNED + TITLE L71i��wp-_- <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ry DATE rP r rS'`-�� <br /> ADDITIONAL COMMENTS: . ` �. <br /> PHASE II GROUT INSPECTION PHA ; AL' INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -&aDATE <br /> .$x1426 Rev. X-74 �. <br />