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vv <br /> SlAm JOAQUIN LOCAL HEALTH DISTRICT ,-*�U <br /> FOR OFFICE USE 1601 Hazelton Ave. , tockton <br /> Telephone: (209):,46_61 <br /> APPLICATION FOR WELL CONION OR PUMP PERMIT Permit No. <br /> THIS PE PIRES 1 YEAR FROM DATE ISSUED Date Issued �O <br /> (Complete In Triplicate) <br /> Application is hereby to the San Joaquin Local Health District for a permit to construct <br /> and/or install th ork herein described. This application is made in compliance with San Joaquir <br /> County Ordi a No. 1862 and they les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESStL;OC*T4" / "�'��S <br /> BUJ�c" ZCru/dttt� d S/4� �c CENSUS TRACT <br /> Owner's Name V a Sp L� �5 .� , Phone <br /> Address City <br /> a <br /> Contractor's Name ©f V WA4t 6 JA P�l , 6lsttq_ S License Oyzy/�, <br /> Phone 3Z/D <br /> TYPE OF WORK (Check) : NEW WELL j / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ O <br /> PUMP INSTALLATION /Y PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L`IN�S �� IT PRIVY <br /> SEWAGE DISP SAL IELD CESSPOOL/SEEPAGE PIT /gj�G I-OTHER <br /> PROPERTY LINE NATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / /`!/4,A <br /> Domestic/private Drilled Dia. of Well Casing !2 Gh _ <br /> _X Domestic/public Driven Gauge of Casing (/& 3 S ,ee P,C <br /> Irrigation Gravel Pack Depth of Grout Seal {- <br /> Cathodic Protection Rotary Type of Grout (— <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorQQy/Zig!/s /5 <br /> Type of Pump t l.� )YLLyS. - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1,�TLE <br /> (DRAW-PLUT'PtAN ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 711.2 17P <br /> ADDITIONAL COMMENTS: <br /> PHAS I G, OUT INSPECTION P I/FINAL INSPECTION N <br /> INSPECTION BY INSPECTION BY DATE <br /> F. H 1426 Rnv . 1_71 . 6/77 2M <br />