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v^t <br /> . ��'i�.�.r�i'."' �tilsew*s.......»,..__,�..^'._.,,.._...... ._....,_»•m»rwtR»a�"k _.:�''�?���_..,:, ���t'°�``, <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FGR OFFICE USE• ' w <br /> 1601 E. Hazelton-Ave., Stockeon, Calif. <br /> Telephone: ' %209) 466-6781 <br /> § APPLICATION FOR WELL CONSTRUCTION.OR PUMP PE&HIT Permit No. <br /> THIS PFMI,`, 1 YEAR FROM DATE ISSUED, Date'Issued" Alt <br /> ` <br /> (Complete In.Triplicate) <br /> <# "Applicatioink'is;heSaw Joaquin,Local Health District for:a'permit�toYcoriftruc <br /> A asd/ori in jtall. the.work harem'described. This::application,ia-madea:in',compliances:.with . Joe <br /> Coua;ye,Ordinaace Na 1862 and the,Rulea.and Regulations of'the San Joaquin''Local`LHealth,Distric ` <br /> JOB /1DDRESSAOCATION ppt,� CENSUS TRACT � L <br /> x <br /> Gfiner�aNamaiy '�1fl,.dr rl Phone <br /> ,Addrssa . <br /> City, f � <br /> Contractor's Name ty�aS License Aa-MPhone ` <br /> i i J°'tt e <br /> TRPS OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /_� DESTRUCTION /7n <br /> s . ' PUMP 4. <br /> INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT LT k <br /> Other_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i= r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER w <br /> r INTENDED"`USE * TYPE"OF WELL ^OESTRUCTION SPECIFICATIONS. <br /> r ' IndustrialCable Tool Dia. or Well-Excavation , <br /> c Domestic/private Drilled Dia. of Well Casing , <br /> { � Domeetic/public Driven Gauge of Casing <br /> ;Irrigation Gravel Pack Depth of Grout Seal <br /> ' <br /> Other: Rotary Type of Grout. rY �. <br /> Other "Other Information <br /> is M <br /> P64"-INSTALLATION: Contractor , <br /> Type of Pump _ <br /> PUMP REPLACEMENT: L/ State Work Done <br /> 9 ' $ <br /> PUMP REPAIR: /7 State Work Done4 > <br /> + ,)W=CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ' °' F . <br /> I hereby agree to comply with all laws and regulacions of the San Joaquin Local Health Diatrict } <br /> and,.the.State, uf California pertaining to or ragulating well construction. ,' WithiaFIFTEEN DAYS ` <br /> w <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 •yell and notify them before putting the well in use. The above t <br /> I informati r A to the bas of my knowledge and belief. r - <br /> SIGN TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ., <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> r <br /> APPLICATION ACCEPTED BY �� DATE ia"&. ' <br /> ADDITIONAL COMMENTS: <br /> V <br /> PFASE II GROUT INSPECTION PHASE III FINAL INSPECTION K <br /> INSPECTION BY DATE INSPECTION BY - DATE ��-'b7. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 4/72 1M C:� <br />