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i <br /> SAN JOAQUIN LOCAL'.,HEALTH iSTICI'`'' 1 <br /> 1601 E. Hazelton'Ave.., :Stocktoh Cal`if'a" � <br /> FOR('OFFICE USE• _ <br /> Telephone-: .:.a (209)'4b6-6781 ,. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNIF PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 :YEAR, FROM- DATE '.ISSUED Date Issued <br /> In-Triplicate) . <br /> P : <br /> a .(Completeo ca>�struct <br /> 4 . <br /> Application is hereby made to the San Joaquin Local:,Health.Di"st�rict: for^.a •pexmit t <br /> end/or install the work herein described. This application,;is;.made in ' ompliance with San Joaquin <br /> County Ordinance Na. 7862 and the Rules and Regulations:of °theSandaqun Local Health District. <br /> 3 b 6 5 N . G o 9 n,° R t1 CENSUS TRACT <br /> JOB ADDRESS/LOCATION 1 tl .G£ 77,77777-77, <br /> ry } Phoney 9 31-h800 _ <br /> Owner's Name farrir Celle _ 4 <br /> . ._"'. :_ .. City <br /> 'Address P.O. .Box 187 Linden Cas "95236- " <br /> _ ,. License Phone <br /> f Contractor's Name iL <br /> TYPE OF°WORK (Check) : I' NEW WELL'/? DEEPEN `/� RECONDITION /7• DESTRUCTION <br /> �i PUMP INSTALLATION / PUMP REPAIR /� PUI�' REPLACEMENT f7 <br /> Other El <br /> DISTANCE TO NEAREST: oiSEPTIC TANK SEWER LINES PIT PRIVY <br /> j SEWAGE DISPOSAL )FIELD CES /SEEPAGE PIT OTHER <br /> „, ROPERTY .LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS : <br /> t` Ind— ustria3 Cable Tool Dia. of Well Excavation i <br /> r Drilled Dia. of Well Casing <br /> Domestic/ Driven Gauge .of Casing . . <br /> 4 Domestic/public { <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> CRotary Type of­Grout <br /> Cathodic Protection ` <br /> Other Other Information <br /> Disposal <br /> Geophysical Surface' Seal Installed B)r: <br /> . <br /> ' � - . . ._ �, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. — <br /> PUMP REPLACEMENTState Work Done <br /> PUMP .REPAIR: L-7 <br /> ES•TRUCTION OF WELL: ' v Well Diameter Approximate Depth 1001 : <br /> Describe Material and Procedure Clean Sand to' 'thin 50f of gtgund <br /> level•. concrete to 9round level <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 'construation. Within FIFTEEN DAYS <br /> after completion -of my work on a new well, I will furnish the. San. Joaquin Local Health District <br /> WELL DRILLERS REPORTIof 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 GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION: <br /> SIGNED TITLE(DRAW-PLOT-PLAN"ON"REVERSE' SIDE <br /> FOR�DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION- ACCEPTED BYE ,— DATE <br /> ` _ �7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I Z/FIN INSPEC�- - <br /> INSPECTION <br /> BY �' DATE INSPECTION BY TE t <br /> -74. 2M <br /> E H 1426 . Rev. i-74 1 <br />