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SAN JOAQUIN LOCAL HEALTH D'I'STRICT <br /> For <br /> tOFFICE USE: 1601 E. Hazelton Ave. , 'Stocktori; .Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75�S�/t <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED Date Issued //-9 <br /> (Complete In Triplicate)- <br /> Application is hereby made to the San Joaquin Local-..Health.District for a permit to construct <br /> and/or, instal,l the work herein described. This application is rkade in compliance with San Joaquin' <br /> County Ordinap e No. 1 62 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> DRoESS/LOCATION df a HT1 ' � a� `J f <br /> JOBJAD <br /> ,l(9jq�2aBSjI�/�'�'1/ CENSUS TRACT � <br /> Owner's Name / �} �/ Phone �� <br /> Address ��� }7V '- � City <br /> Contractor's Name z-T/¢ !f /y p—5 _ License #16�L 37.?hone J1 6/6%g,)J <br /> TYPE OF WORK .(Cheek).6 NEW WELL/7 DEEPEN -/7- RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN , ,R LINES N 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 p : 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 /> Cathodic Protection -'- Rotary Type of"Grout- fi <br /> Disposal Other _ t Other.,Information <br /> Geophysical ' Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />""PUMP .REPAfiR:"""� x `- Stat�TWbrk Done%- �' T7�' 1 <br /> ES1RUCTION OF WELL: Well Diameter Approximate Depth <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 o£ 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 GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> -SIGNED TITLE <br /> (DRAW PLOT- PLAN ON REVERSE SIDE <br /> F R DE NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY T DATE <br /> ADDITIONAL COMMENTS.: � <br /> PHASE II GROUT INSPECTION PHASE III/JFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y75 <br /> ti. E H 1426 Rev. 1-74 1-74 2M <br />