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L U� SAN JOAQUIN .LOCAL 'HEi'LTH DISTRICT <br /> t FOR OFFICE USE: 1601 E. Hazelton Ave. , Stgcktor,, 'Calif. <br /> Telephone: (209) 466--6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z _ S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued-5 Z'�7 I/ <br /> (Complete In Triplicate) I q 75c — i <br />! Application is hereby made to the San Joaquin Local' Health District for a permit to construct E <br /> and/or install the work herein described. This application is made in with San Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> j Owner's Name <br /> Phone <br /> Address <br /> Clty C.c��i=�% ✓�. <br /> Contractor's Name r J,, License. # � Phone ' 4 . Z ,S <br /> TYPE OF WORK (Check) : NEW WELL IX/ DEEPEN /`7 `.RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION /j/ PUMP' REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTEND---ED USE TYPE F WE i 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 r � <br /> Rotary - Type �of Grout = t <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ) H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR•:-- - / / -State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> FaTADprox mai fit epth <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, 'l 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. <br /> SIGNED <br /> TITLE <br /> (DRAW PL PLAN N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I - <br /> APPLICATION ACCEPTED BY �c-� DATE <br /> ADDITIONAL COMMENTS: ly <br /> PHASE II GROUT I SPECTION PHASE III/FINAL IN <br /> INSPECTION INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIOr <br /> E H 1426 4/72 1M <br />