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SAN JOAQUIN LOCAL".HEALTH DISTRICT <br /> FORri]FFTCE USE: 1601 E. Hazelton Ave. , Stodkton, }Cal 'f. <br /> Telephone: , (209) 466 .6781 <br /> G APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 744- 37 4) <br /> THIS PERMIT EXPIRES 1 YEARfFROM-DATE.`ISSUED ° t �' Date''. Issued <br /> i , r . <br /> (Complete In Triplicate) i . <br /> Application is hereby made to the Sar: Joaquin Local Health Distri=cfi:,for.-a peri:it to-construct <br /> and/or install the work herein described. This application•.is made.in compliance.with�>San,Jd'aquin <br /> County Ordinance No. 1862 and the Rules and Regulations ;of the,:San• Joaqu rt:Local,-Health-DittrictY <br /> JOB ADDRESS/LOCATION a fgZ CENSUS TRACT • .' - <br /> Owner's Name Phoneh , <br /> Address - _ . .:� �. �u___�...,_. . <br /> ��City" <br /> Contractor's Name . -- License # Phan <br /> TYPE OF WORK (Check): NEW WELL .f DEEPEN /_7 RECONDITION /_7 •DESTRUCTION- . <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL -CONSTRUCTION SPECIFICATIONS 711 <br /> Industrial Cable Tool Dia. of Well Excavation U " <br /> X Domestic/private ' Drilled Dia. ,of-Well Casing <br /> Domestic/public Driven Gauge,of Casing /.2. <br /> Irrigation, Gravel Pack Depth of Grout Seal Sp ' <br /> Cathodic Protection Rotary Type -of Grout- -C¢ <br /> Disposal Other Other. Information <br />+ Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor = ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done ' <br /> PUM i.REPAIR: /? State Work Done <br /> r <br /> ES;TRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> I hereby agree to comply with all laws and regulations of the San ioaquin 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 /> WELL DRILLERS REPORT of the well and notify them before putting.. the .well in use.. The above <br /> information is true to the best of. my knowledge and belief. I WILL CALL FOR A tkouT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED _. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PRASE I <br /> ' APPLICATION ACCEPTED BYA DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II O PHASF _IZZIFINAL INSPECTION <br /> INSPECTION BYA E - INSPECTION BY DATE J(, .�_►� <br /> " � E H 1426 Rev. 1-74 1-74 2M <br />