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^nr s I! SAN .)OAQIL.11� 1,0CALL <br /> v OFFICE USE: � 1601 E. Hazelton Ave. , Sto;.k[c,n, Calif. <br /> Telephone (209) 466--6781 <br /> APP KATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> :I 1 B <br /> THIS PERMIT EITIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (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 hereiii described. This application is made in compliance with San JoaquiF <br /> County Ordinance No,. 1862 ands--,the Rules and Regulations of ihe� San Joaquin Local Health District." <br /> JOB ADDRESS/LOCATION <br /> .f . <br /> CENSUS TRACT . <br /> Owner's Name /?�' .� " _ . <br /> Ph;_one <br /> Address r I � - � <br /> City, <br /> Contractor's Name <br /> License = Phone �= <br /> TYPE OF WORK (Check): NEW WEL'L '/-7 I}EEPEN <br /> / / RECONDITION /__7 DESTRUCTION / <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> �7ISTANCE TO NEAREST: SEPTIC TANK. - SEi3ER LINES .__ PIT PRIVY -- <br /> 5E�TAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE .. TYPE OF WELLFCOt;STRUCTION =SPECIFICATIONS <br /> x Industrial. Cable Tool .]J" a, of ttiTell Excavation O <br /> _ Domestic/private Drilled ' Dia. of Well Casing <br /> Domestic/public . Driven r Gauge of.Casing <br /> Irrigation S <br /> Irri ac a <br /> ravel Pack Depth of G=out Seal <br /> Cathodic Protection Rotary Type of Grout" ' <br /> Disposal f- 5� Other -.-Other information <br /> GeophysicalSurface Seal Installed B '} <br /> PU2T INSTALLATION: z � <br /> Contractor <br /> Ts-pe of; Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / j State Work- Done _ <br /> ItSTRUCTION OF WELL: Well Diameter (E ;' <br /> Approximate- Depth G 7 <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 /> 4ELLmDRILLERS REPORT of the well. and notify them-before putting. the..wel'I" in -use.. The above , <br /> Information is true to the best of my knowledge.Fand •belief. I WILL CALL FOR A G NSPECTION <br />'RIOR TO GROUT, NG AND AFI AL INSPECTION.',; <br /> 3IGNED <br /> TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DE TMENT USE ONLY <br /> d;PLiCATION ACCEPTED BY 00Y <br />,DDITIONA.L COMITENTS: DATE <br /> PHASE II GROUT INSPECTION . PHASI /F NSPECTIO <br />:vSPECTION BY i DATE INSPECTION BY ATE <br /> F <br /> E H 1426 . 'Rev. 1-74 <br /> 1-74 W <br />