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SAN JOAQUIN LOGA '.HEALTH DISTRICT .� <br /> FOF�rOFFICE USE: 1601 E. Hazelton Ave., ':Stocktari, Calif. <br /> Telephone: x(209)_ 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERXIT Permit No- <br /> THIS <br /> o.THIS PERMIT EXPIRES 1- YEAR FROM`DATE'ISSUED Date Issued <br /> w ete,ln Triplicate) <br /> lt` a Joaquin Local. Iieal,th District fax a permit to construct <br /> AppllcaCian is hereby made to the San <br /> and/or install'4he work herein described. This applica'tian is wade in compliance with San Joaquin <br /> 2 and..the <br /> County Ordinance No. 186ules and Reg ations ' <br /> the San Joaquin Local Health District. <br /> �0Z - 'c CENSUS TRACT Q p <br /> ADDRESS LO -. � '� `�-C,- <br /> '� <br /> CATION � <br /> JOB / <br /> Phone <br /> Owner's Name <br /> - 4 <br /> Address .�~ - T c� -� ,.».r -. City <br /> License # Phone `7 4~3 YSG <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL -/ DEEPEN '/ / RECONDITION IwT. DESTRUCTION I�T <br /> PUMP INSTALLATION ( PUMP REPAIR PUMP REPLACEMENT// T 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC !TANK SEWER LINES PIT PRIVY <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r: PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL n l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Y� <br /> Industrial Cable Tool Dia. of Well Excavation \ <br /> rivate Drilled . Dia. of Well Casing <br /> . <br /> Domestic/private - - <br /> Domestic/Publ.i�c . . _ ,Driven :_ Gauge of�C sing <br /> GrvelDe th of Grout Seal <br /> Irrigation; p*, <br /> Cathodic Protection Rotary Type ofGrout. <br /> Disposal ;< '� Other _ - '`O'tiher'Information <br /> Geophysical' Surface Seal Installed BY: <br /> PUMP INSTALLATION. Contracto ° t, 'e- •' <br /> it <br /> Type of Pump H.P. .�.. c <br /> PUMP REPLACEMENT; // <br /> FState Work Done <br /> PUI� '.REPAIR: /7 State Work Done <br /> 'l Approximate Depth <br /> RESTRUCTION OF WELL: Well :Diameter <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my workion 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 GROUT INSPECTION <br /> i PRIOR TO GROUTING ANDA FINAL INSPECTION. F <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN" ON REVERSE SIDE <br /> {-� FOR DEPARTMENT USE ONLY <br /> PHASE~I ' '. DATE <br /> APPLICATION -ACCEPTED BY <br /> j ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HA III/ N INSPECTI <br /> f INSPECTION BY = DATE INSPECTION BY ATE <br /> :1-7 4 2M <br /> i E H 1426 : Rev. I-74 r _-- <br />