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Za 3- 7/d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT /,-7 <br /> f'O�.:OF ICE USE: 1601 E. Hazelton Ave. , Stock& 781 tont Calif. <br /> Telephone <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a <br /> 4 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein <br /> described. <br /> This <br /> Regulationstofnthe Sanis Joaquin in liance with S <br /> Local an J,paquin: <br /> andDistrict* <br /> County Ordinance No. 1862 and theRules <br /> � e , <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> City — <br /> Address <br /> LLzNO COS. 1110, x.6322 "P 561+3 <br /> Contractor's NamIM Mi N t License � Pho <br /> TYPE OF WORK (Check): NEW WELL /✓I` DEEPEN '/ / RECONDITION /_/ DESTRUCTION I-7 <br /> PUMP INSTALLATION I I PUMP REPAIR I I PUMP REPLACEMENT l�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TLNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Casale Tool Dia. of Well Excavation 11� <br /> Domestic/private /--Drilled Dia. of Well Casing (o <br /> Domestic/public Driven Gauge of Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal Jar 4 <br /> Other ✓'Rotary Type of Grout <br /> Other _ Other Information , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump x'P' ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> f <br /> PUMP 'REPAIR: / / State Work Done <br /> fi Approximate Depth <br /> DF'TRUCTION OF WELL: Well Diameter <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 Joaquin Local Health District 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 knowledge and belief. <br /> �` d INGS .'i 3 <br /> DRILLING CO t INC a �. 't <br /> A SIGNED TITLE G� <br /> °i <br /> ON R <br /> (DRAW PLOT PLAN REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I � C j' / DATE S <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: 7 pHAS I/FINAL INSPECTION <br /> PHASE II_ GROUT INSPECTION DATE' ' <br /> INSPECTION BY - ---f. DATE <br /> INSPECTION BY "� <br /> -CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M <br />