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NNW, <br /> �A( -.1LI11k, <br /> PE"RIVIT EXPIRES I YEAR 1'a0": DATI", S 1 F." <br /> (Comp lett: In T,.ipjJcate) <br /> Application is hereby made Co the San Joaquin Local Health District for a permit to construcr- <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> r, "L <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION g 9 4 /?1 V h CENSUS TRACT <br /> Owner's Name ro Phone <br /> a- : - C <br /> Address 47 <br /> A , L, ,, , r <br /> A J., city <br /> Contractor'F NA ame L/-:Ql i!-::1 License # none <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION DESTRUCTION 1-7 <br /> PUMP INSTALLATION PUMP REPAIR —PUMP REPLACEMENT- /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT--- OTHER <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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other > Rotary Type of Grout <br /> Other Other Information <br /> ?UNP INSTALLATION: Contractor I <br /> ,Z L <br /> Type of Pump 5 H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material land Procedure <br /> 1 hereby agree to c'mp I ywith all laws a regulations of the San Joaquin Local Health District <br /> and the State of Ca ifornia pertaining tc or regulating well construction. Within FIFTEEN DAYS <br /> after completion of work on a new well , I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use. The above <br /> information true <br /> .to he bf-st o ., my knjwledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSESIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED <br /> BY DATE <br /> ADDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPECTION PHAS5,III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 61 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT14/. <br /> Z H 1426 <br /> 4J,2 1M <br />