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SAN JOAQUIN LOCAL"HEALTA DISTRICT <br /> PQErOFFICE USE: 1601 E.. Hazelton Ave.., Sfock•tan, Calif. <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES' l YEAR -FROM. DATE ISSUED Date Issued <br /> (Complete -In Triplicate) <br /> Application ,is hereby made to the San Joaquin Local•;,Health District for a permit to construct <br /> and/or install .the.work herein described.. .This application..is :Wade in compliance with San Joaquin <br /> County Ordinance No:.1862 and the Rubs and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> _ CENSUS TRACT <br /> Owner's Name 10..A4 TE 6 ,7c /0 A/8 ��< Phone <br /> Address-- .l,VIj AJt- City �. <br /> Contractor's Name r ori - License #_? _yo)`0 Phone <br /> l <br /> TYPE..OF WORK (Check):' NEW WELL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION f7 - .� <br /> PUMP INSTALLATION /—/ —PUMP.REPAIR 0PUMP REPLACEMENT /_7 _44I -Other � <br /> i 1 <br /> DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> /pubN .:„ -- <br /> ublic Driven Gaugeof Casing <br /> Itril anon :� ..., <br /> � `g �`"'�`- �""°'-"��"Grave].wPack Depth of Grauv Seal <br />( � Cathodic Protection Rotary Type of Grout <br /> i Disposal Other Other Information <br /> Geophysical Surface--Seal Installed By: <br /> t PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. <br /> PULP REPLACEMENT: / / State Work Done 1 <br /> PUMP REPAIR: - _. <br /> 'State Woxk° Done o <br /> S&TRUCTION 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 alcove <br /> information is true to the best ofmmy.knowledge and belief. I WILL CALL FO 'A GROUT INSPECTION <br /> PRIOR TO GRO NG AND AnFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ct _ // DATE � �S <br />! ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 7��A_ l DATE <br /> E H 1426 Rev. 1-74 1-74 2Ma;, <br />