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S/LN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. HazRlton.,Ave,.., ,.Stocktrt-., Calif.' <br /> Telephone:. - (209)- 4LS6'-6781 <br /> APPLICATION FOR WELL CONSTRUCTION: OR PUMP PERMIT Permit No. 7 T 0 <br /> THIS PERMIT EXPIRES 1- YE&R'FROM DATv, ISSUED Date Issued <br /> _7 <br /> .In-Triplicate) <br /> Application is h ­-bzy <br /> ere I_made,'to theiSan,Joaquin Local Health District for a permit to. construct <br /> and/or install the work:,�herein described. This application is made in compliance with San. <br /> Joaquin .� <br /> County Ordinance No: 1862 and,zithe Rules and Regulations of the San Joaquin.�Local ,Health District. <br />�OB,ADDRESS/L' OCATION *9 dw 4z� CENSUS TRACT <br /> Owner.'s,Name kAl <br /> Phone <br /> - <br /> Address City <br /> Contractor's Name A) License # '-Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN '/—/ RECONDITION /7 DESTRUCTION /7 <br /> v i <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMEN�T— <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL F1gLD 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 /> D6m6gtic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ,'Contractor S kj,q, ix, <br /> Type of Pump se_,bl H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> 'OF <br /> PUMP REPAIR: 'State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> afte"r 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 above <br /> informatio is true to the best of Day .knowle-dge and belief. <br /> SIGNED "N <br /> 7 <br /> LE <br /> MEW PLOT PLAN ONjgQ!,RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> .APPLICATION ACCEPTED BY <br /> 3 . , DATE;g <br /> ADDITIONAL COMMENTS: 0 42 <br /> PHASE II GROUT INSPECTION V PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 'DATE 1-61- --o- 7Z <br /> re, <br /> CALL FOR A GROUT INSPECTION,VRIORJO �GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />