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SAIN JOAQU?N LOCAL iiEALTH DISTRICT <br /> FOR OFFICEUS'`: 1601 E. Hazelton Ave., Srocktnn, C-14f. <br /> \f 1 <br /> Telephone: (209) 466-6753. f } <br /> �w'LICATION FOR WELL CONSTRUCTION OR PU�3' PERMIT Permit No. 17-0 <br /> THIS PERMIT EXPIRES 1 YEAR Fr= DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local dealt: District for a permit to construct <br /> mpliance with;San Joaquin <br /> and/or install the work herein described. This application is made in co <br /> gulations. G£ the San Joaquin LncaZ.'�ieaith Bistrict. <br /> County Ordinance No. 1862 and the Pules and.Re <br /> CENSUS TRA <br /> Li�iA il'�c.��' <br /> ,5 JOB ADDRESS/LOCATION �2 <br /> Phorie., W d <br /> : Owner's Namel <br /> Address City { �� <br /> X373 �3 <br /> -- License Phone <br /> Contractor's.Name --— <br /> f <br /> TYPE OF .WORK (Check): .; NEW WELLI�j' DEEPEN 17 RECONDITION /7 DESTRJCTION I T c <br /> �y`fa <br /> . PGs!P INSTALLATIOii'I / . £ulnr .REPAIR PUMP REPLA�;EMENT - I . <br /> s'` s Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER.LIN85 PIT. PRIVY <br /> f� SEWAGE <br /> AL. CsSPOOL/SEEPAGE PI'I OTHER '�INTENDED USE "YPE OF 14ELL . CONSTRUCTION SPECIFICATIONS ,tN <br /> Industrial Cable Tool Dia. of Well Excavation. <br /> ` <br /> Drilled Dia: of.Well Casing <br /> uiestic'Iprivate Gain e: of Casing <br /> w _ <br /> 1w �4 Domestic/Puy Driven g 8 <br /> Gravel Pack Depth of .Grout Seal <br /> ,.-.. Irrigatior' <br /> Z Other __ Rotary Type of Grout <br /> Other Other:Information: " `- <br /> PUMP INSTALLATION Contractor <br /> Type of Pump <br /> vv <br /> J' e Work Done <br /> :PUMP:REPLAGEMENT: Stat <br /> / /. , <br /> PUMP REPAIR State Work Done +. <br /> Approxdmate Depth �"�s _ <br /> ,DESTRUCTION.OF WELL: Well Diameter. —� Y <br /> Y Describe Material and Procedure <br /> I herby <br /> agree to tompiy with all laws and regulations of -the San Joaquin LocaZ;Health District <br /> � . <br /> an State of California pertaining to or regulating well construction.: Within FIFTM. DAYS <br /> t* tr _`after:completion of my work on a new well, I will furnish the .San.Joaquin ;Local,Ftealth'District a i <br /> ".,,"v <br /> We.LL: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 /> r <br /> TITLE <br /> ' SIGNED (DRAW PLOT PIAN ON REVERSE SIDE <br /> FUi DEPARTMENT USE ONLY " <br /> PHASE Z DATE �~ z <br /> APpLICATION ACCEPTED BY. <br /> ADDITIONAL.COIvA ITS <br /> ,.PHASE'II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE TY <br /> INSPECTION BY DATE. <br /> v; GT P <br /> i:AI.L FOR A GROUT INSPE:TIO.£.PRIOR TO GROUTING A%, FINAL INSPECTION 4/72'' 1M <br /> E H 1426 <br />