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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ME USE:- 1601 E. Hazelton',,'Ave. ,,,5gtockcoil, Calif <br /> 74 -7 6 <br /> `/'466 6 7 81 <br /> Telephorie:i4 2'09) Permit No- <br /> \APII�ICATION FOR WELL CONSTRUCTIONt-OR PUMP PERMIT <br /> 'd, -7 <br /> j,--sI.SSUEDb'­'�1 'i-,Date,~J.s6ue 7 <br /> YEAR-!FR0M,,;­DAT__ Z <br /> HIS PERMIT EXPIRES r:1 <br /> (Complete inRTt1P1i-dat?2)' <br /> Ap p li ca ti oA fi.46hAeby'-,made the--.San�Jo`aquin-IL06ak Adal�'h D strictafcsr=a permi <br /> jiaTv64-_�with.�,Saj%-,,J-6aq <br /> Th p .is tmade j'iti--._-c0MP <br /> and/or install the work herein described. � j-'6,:Apf llcat,ibn , . e- 'Di8tr-ic <br /> Count y�,OrdinaticecNo-.r�_1862f.,�and \th,6,:Rules 1'�andnRegula'ti'OAS�:'6fr'the,.Sa,li.tJ-oa4;Aitl,:L6eal.'H althL <br /> 8 <br /> RACT"-� <br /> ;,f,CENSUS-,T <br /> t-A 0 10 I'to ERS T/6�Y <br /> JOB ADDRESS/LOCATION t/001 s" 6vi 7m 3.UT f,�)Od <br /> Ir.I-,.0?w ..1 <br /> Owner!s5N.a­m&01 a <br /> TE L3 F__ <br /> Address Is tl A)Y-f; SCit orb <br /> 5'44 <br /> License Phone *?*_7i-2� <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL �l DEEPEN RECONDITION DESTRUCTION '/_7 <br /> PUMP REPAIR -7 <br /> PUMP INSTALLATION '/ R '/ PUMP REPLACEMENT <br /> Other? <br /> DISTANCE TO NEAREST-: SEPTIC'TANK­ 511- SEWER LINES. PIT PRIVY ' <br /> I <br /> SEWAGE,.DISPOSAL FIELD . -CESSPOOL/�SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF <br /> WELL !- a CONSTRUCTION SPECIFICATIONS. <br /> Industrial 1_.)��__C:Ile Tool'-. Dia. of Well Excavation <br /> Domestic/private j t DrilledA Cry," .o: <br /> S? <br /> Dia. of Well Casing <br /> Domestic/p4blic .,,,Driven Gauge of Casing 1,0L <br /> of. Grout Seal <br /> Irrigation L-Gravel-Pack. . ',..,Depth' — 6.2 <br /> Other y RotaryType of Grout <br /> OtherI Other Inform-ation <br /> PUMP INSTALLATION: Contractor <br /> Type of .Pump H.P. * <br /> PUMP, REPLACEMENT: State Work Done ' <br /> PUMP REPAIR: 7 State Work Done <br /> .DESTRUCTION OF WELL: Well Di4meter Approximate Depth- <br /> . Describe Material and-Procedure <br /> I hereby agree to comply with all laws .and, regulations of the San Joaquin Local Health Distri4 <br /> and the State. of California pertaining to or-regulating well construction. Within FIFTEEN DX <br /> after completion of my"work'bn a new well, I will furnish the San Joaquin' Local Health Distrix <br /> i WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true. to the-b6st 'of my knowledge and belief. . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTSk 90 <br /> PHASE II GROUT INSPECTION PHAS4,,TIIJFINAL INSPECTION <br /> INSPECTION BY �IW I DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION./7 <br /> X72 <br /> !W< <br />