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(liti " c TKM <br /> yyr 4 - SAN JOAQUIN LOC-kL HEALTH DISTRICT <br /> 3. FOR.OFPICB USE: 1501 E. 'azelton Ave. , otockton, Calif. - <br /> ' <br /> (2(10) 466-6781 � �y � <br /> APPLICATION S- 'ONSTKUCTION OR PUMP PERMIT Permit No, 7S'- t <br />� r <br /> THIS P'"R IIT -� .cE.S 1 YEAR FROM DATE ISSUED Date Issued <br /> (C%Aplete In Triplicate) <br />;- Application is hereby made un the San Jt)aquin Lr-ai Health District for a permit to construct <br /> and/or.install the rock h,.eia a-acribed. 1'hir, -.,plication is made in co-,pliance with San Joaquin <br /> M _ Couatj Drdinauce N->-- a P--,' and the Rule:, lord Regulations of the San Joaquin Local Health District- <br /> CENSUS <br /> istrict- <br /> CENSUS TRACT w <br /> JOB ADDRL'- n 1TION ` <br /> owner's lip-As <br /> Addrees== <br /> License Z�P'hrue "J ~ <br /> Contractors Name <br /> T:'P8 OF WORK (C'neck): NEW WELT, �7 DEEPEN /_� RECONDITION /7 DE-RUCTICN L7 s <br />' r - PUMP INSTALLATION /-7F'U?T REPAIR /-'] PUMP REPLACEMENT '7 IZ4 ' <br /> Other /? <br /> ' DISTANCE TO NEAREST: SE] TANK SEVER LINES PIT PRIVY f <br /> SEWAGE DISPOI FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PIBLIu DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIIN SPECIFICATIONS <br /> r Industrial Cable Tool Dia. of Wel: Excavation /..I +P <br /> Domestic/private Drilled Dia. of Well Casing <br /> .3 Domeotic/public Drives Gauge of Casing <br /> Irrigation Gravel Pack Deptb of Grout Seal <br /> Cathodic Protection yt Rotary Tvpe of Groat <br /> Disposal Other Other Information v � <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATIOtIi Contractor <br /> 9,,— r � <br /> Type of Pump <br /> � I <br /> " PUMP REPI.ACEMENT; /% St-ate Work Done <br /> i <br /> a PiI?Os REPAIR: /^i State Work Done _ <br /> tES`TRU+:TION OF WELL: Well Diameter AppTcximatt Depth i <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 =iealth District a I <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> s information is true to the test of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G_ UTING ,DFI INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PIAT PLAN ON REVERSE SIDE � <br /> FOR TMENT USE ONLY <br /> ?H;SE I / Gf/ DkTE 7 r_ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMMS: <br /> PHAS" IZ'" <br /> =OUT INSPECTION PHASE FI .iSPECTION � <br /> -T �4 INSPECTION BY DATE —7S <br /> INSPECTION BY DATE � � <br /> I <br /> ` - E H 1426 Rev 1-74 1-74 2M <br /> f <br /> s <br />