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SAN JOAQUIN LOCAL HEAL.TIT3D S it l <br /> ICE USE: 1601 E. Hazelton Av St4 Cali . <br /> t4 <br /> FOR OFF Telephone: 9j X6'6-6781 ` <br /> APPLICATION FOR WELL CO UCTIOI&OR Pa PERMIT Permit No. �w-- <br /> Date Issuedy <br /> THIS-PERMIT EXPIRES 1 YEAR FROM" ,., C <br /> (Complete In , 1_ e '. a '3' <br /> Application is hereby made to the San Joaquin LocaT� I �'i.t district for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San .Toaqu tt; <br /> County Ordinance No. 1862 and 'the Rules and Regulations of the <br /> `Joaquin Local Health District. <br /> f� NSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> . :-Phone <br /> Owner's Name �i <br /> F _ City <br /> Address D a <br /> ! License ��jG�3 73 Phoneld 3 <br /> Contractor's Name �`r ! <br /> TYPE OF-WORK (Check) : NEW WELL /-7.-DEEPEN /� RECONDITION /� DESTRUCTION-/77- <br /> TYPE <br />` PUMP INSTALLATION. / PUMP REPAIR / `FUME REPLACEMENT <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.,;D.ISPOSAL. FIELD..- CESSPOOL/-SEEPAGE -PIT OTHER <br /> INTENDED USE TYPE OF WELL' <br /> 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 /> Gravel.-Pack k" Depth�'o Grout Seal <br /> " Other Rotary. Type of Grout <br /> a Other Other Information <br /> f <br /> PUMP INSTALLATION: Contractor ' H.P. <br /> Type of Pump <br /> ! PUMP REPLACEMENT• �C� 'S tate Work D©ne�,c• C 0��f <br /> tate Work <br /> S � <br /> PUMP REPAIR: / t, — -- - - - -- <br /> Approximate Depth <br /> ESTRUCTION OF WELL: Well Diameter <br /> al <br /> Describe Materi :and Procedure <br /> t . <br /> I he 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 weld and notifyw weli, lthemlbeforesputtingatheowellnin�use.cal HeThehaboverict a <br /> WELL DRILLERS. REPORT of the <br /> ; information is to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED (DRAW PLOT—PL T ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> - APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> , INSPECTION BY DATE INSPECTION BY <br /> CALL FOR FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 lM p <br /> E H 1426 <br />