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SAN'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE.,/- 1601 E. Hazeli�'bn Ave. ,.,.5tockkon, Calif. " <br /> Telephone: (209) 466-6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?2-- 8 `� W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued10-( j-i v <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 described. This application is made in compliance with San Joaquin' <br /> County Ordinsnc j 9. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> a;e Phone ' :54'7r__ <br /> Address <br /> City f <br /> G <br /> Contractor's Name _ <br /> License # Phone -� <br /> �W <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION & PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK / '4�SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T(FE OF WELL <br /> .�� CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of. Well Excavation { <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing "!2 , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 17C/J <br /> Other Other Information <br /> Fi4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. { <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP REPAIR. / / State -Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth { <br /> 00 <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 c letion of my work on a new well, I will furnish the San Joaquin Local Health District a , <br /> WELL DRI S REPORT of the well and notify them before putting the well in use. The above <br /> informatio s true to the bes of m knowledge and belief. <br /> SIGNER TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION SY DATE ®t� • - / INSPECTION SY _ DATE - 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, "- <br /> E H 1426 7/72 1M <br />