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t SAN JOAQUIN LOCAL HEALTH DISTRIICT� <br /> FOR-0FFICE USE: 1b01 E. Hazelton Ave. , Stocktoa, Calif., <br /> Telephone: (209) 465-6781 IT <br /> N P ( ef f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z" 34 5 <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED , Date. Issued <br /> (Complete In Triplicate) <br /> Application is he eby 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. _4 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> F' <br /> 1. <br /> Owner's Name Phone ' i' <br /> Address ehllj I)lqCity <br /> Contractor's Name License #, Phone <br /> TYPE-OF WORK (Check)-... 1�EW-WELL %-/" -DEEPFN -/ /v -RECONDITION %-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 �1_ s <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 9 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ' <br /> Other Other Information . <br /> PUMP' INSTALLATION: Contractor ,p <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .,DESTRUCTION OF WELL:. Well:Diame.ter. _ Approximate Depth. <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 /> SIGNED <br /> TITLE �z, 1� <br /> RAW PLOT P AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY <br /> C , DATE <br /> ADDITIONAL COMMENTS: , <br /> PHASE If-G-R-09Y INSPECTIONPHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ��'�//^�Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP TION. <br /> E H 1426 4/72 1M <br />