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SAN JOAQUIN LOCAL HEALTH DISTRICT old r K <br /> FOE OFFICE USE: 1501 E. Hazelton Ave. , Stocicton, ,Calif. <br /> Telephone:. (209) 466-6781 ` , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 JJ <br /> Gv �g THIS PERMIT EXPIRES 1 YEAR FROM DATE _ISSUED Date Issued � Z7 <br /> (Complete In Triplicate) <br /> Application is ereby made to the San 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 Joaquin <br /> County Ordinance No. 1862 andd !the Ru. an gulations f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT 04 <br /> Owner's Name / �F Phone66 <br /> Address ✓ 445'7 Cite' { <br /> Contractor's Name Licensa� �3 Phox��1 <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION/ / -PUMP REPAIR fX PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION' SPECIFICATIONS <br /> Industrial ' Cable Tool Dia: of Well Excavation <br /> Domestic/private-­ � `-I ,Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation 1 Gravel _Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ Q <br /> Disposal 1 Other Other Information (� <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - -- H.P. <br /> f <br /> PUMP REPLACEMENT: / / ,; State Work Done <br /> PUMPREPAIR: -'� tate one - - oe <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Describe Material and Procedure , <br /> I hereby agree to comply withlall 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 Health District <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 GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 6A TITLE <br /> ; DRAW PLOT- PLAN 'ON REVERSE SIDE) ' <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> "� � . <br /> APPLICATION ACCEPTED BYr/ A/! DATE -7Z- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIONA7 , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2m <br />