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SAIv'gS�A ',SIN LOCAL HEALTH DISTRICTn, 7c�l� <br /> FORs` irr'I USE: 1601 E. Hazelton Ave. , StocktoCalif. <br /> Tele hone+.:- 7C-l a Y <br /> p <br /> APPLICATION FOR WELL -CONSTRUCTION 5OR1PUMP PERMIT Permit No. <br /> z� <br /> R FROM DATE ISSUED <br /> THIS PERMIT-:EXPIRES 1 YEAR <br /> 1 - i Date Issued. <br /> (Complete In Triplicate) <br /> Application is hereby, de 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 Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health District, <br /> I JOB ADDRESS/LOCATION ' <br /> CENSUS TRACT <br /> Owner Name . . ._ <br /> O <br /> Phone <br /> Address 1 <br /> City <br /> Contractor's Name / <br />' License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN- <br /> RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION _/ / PUMP REPAIR / / PUMP REPLACEMENT /-47 <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CON <br /> RUCTION SPECIFICATIONS <br /> # Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing 6 <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Other Rotary Type of Grout <7-dD J7�ZE , <br /> Other Other Inf�mation <br /> t -- i <br /> f + . <br /> PUMP INSTALLATIONo Contractor r <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br />*-PUMP REPAIR.---- � T <br /> - <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth _ <br /> 3 i <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 /> SIGNED 1. <br /> ' TITLE f E <br /> (DRAW PL PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r� <br /> ADDITIONAL COMMENTS: f/ DATE <br /> P E I ROUT I PEC ON <br /> INSPECTION B P FINAL INSPECTION <br /> DATE . 7Z INSPECTION BY DATE r <br /> CALL F'OR, A GROUT INSPECTION..PRIOR TO GROUTING AND FINAL, INSPECTION. E <br /> E H 1425 <br /> 7/72 IM C T- <br />