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SAN JOAQUIN LOCAL HEALTH DISTRIE,T ( \ 'Al <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Sto tSf�€,. <br /> Telephone: (209) 4 6�` � y <br /> APPLICATION FOR WELL CONSTRUCT flR Psi TER�� Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSV.E L()C -Date Issued <br /> * '0' N t a c�c1;T,,;72,��«M. (Complete In Tri lic g 4;C <br /> 13' � ( P P � � J TR <br /> Application is hereby made to the 'San Joaquin Local Healti �ii Ct for a permit to const uct <br /> and/or install the work herein described. This .application is made in compliance with San Joaquin <br /> County ,Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � `yj. / CENSUS TRACT . <br /> Owner's', Name ' <br /> Phone '3 4 �� <br /> Address L -)' City <br /> Contractor's Name License #/4_-37 ? Phone7 - 3 <br /> TYPE OF�WORK (Check) : NEW WELL /7 DEEPEN /`7 RECONDITION /-7 DESTRUCTION /-7 W <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT , <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1[ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS D <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 /> Oiher Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.p, <br /> PUMP REPLACEMENT: State Work Done P"- <br /> PUMP <br /> PUMP REPAIR: / / State Work Done <br /> ETRUCTION OF : Well Diameter { <br /> PSWELL <br /> _ , Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San <br /> Joaquin Local Health District <br /> and the State of California pertaining to or regulating well cons ction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish t 9a Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putt g he well in use. The above <br /> information true to the bes of my knowledge and belief. <br /> SIGNED <br /> (DRAW PLOT PLAN OWYL&VE IDE - - --- <br /> FOR DEPARTMA$t-Mjbfty <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> (.1_. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE __J�� SPECTION BY DATE <br /> CALL :FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1.426 7/72 100 <br />