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SAN:�JOAQUIN LOCAL 11EA%.TH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave. , Stoc .tn . , Calif. <br /> °K Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUM> PERMIT Permit No. 22-21,v � <br /> THIS PERMIT MFIRES 1 YENR ICOM .DA','I__ISS ED Date Issued <br /> (Complete In Triplicate) <br /> .Application is hereby made totheSan Joaquiri` Local Health District for a 'permit to construct <br /> .and/or install the work hereip described. This-applfcation is,made in compliance with San Joaquin <br /> County Ordinance No. 1562 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION- / CENSUS TRACT -�-/ <br /> Owner's Name Phone ' X7 �CJ3 5 <br /> Address City �� >•. <br /> Contractor's Name _,._. <br /> License # Phone �3j zl_ _1�111 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUY2 REPAIR / / PUMP REPLACEMENT / <br /> Other / € <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS # <br /> IndustrialI Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. of Well Casing _j � <br /> Domestic/public j. Driven ------Gau.ge of Casing � <br /> rr gation - _� -Gravel Pack-�--��Depth�of^Grout;Sea-1 <br /> �... <br /> Other"' Rotary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r° <br /> PUMP REPLACEMENT: / / State Work Done.! - <br /> PUMP REPAIR: / / State. Work Done <br /> ;DESTRUCTION 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 of 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 M'V.. knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY - fj�� . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7o7-6=71L- t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 11�,, <br /> t� � <br />