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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1601 E. Hazelton Ave.4 Stocktg1q, Calif. <br /> Telephone:.1,. (209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP: PERMIT _> ;' -Permit.-No. Tu <br /> THIS,PERMIT,WIRES 1 ,YEAR FROM DATE °ISSUED Aate Issued <br /> X23::1-�r= �o..�'E�-?�-FSE-=�� #, - (Comp�,ete In Tripl�aate) . •.- r <�07'�'�3Cv�o -�r� <br /> Agg #cation is hereby made to the San Joaquin Lvcal kIealtl pistric : for a•:permi't,.'to construct <br /> acrd/or install the work °herein described. This' application is ,made• ,in; .-..with Saa..,3oaquin <br /> Countq Ordinance Na. 18b2 acrd the Rules and Re$ulations, of the Sane3oaqu n Local Health:'District. <br /> JOB ADDRESS/LOCATION <br /> .,� <br /> Owner's Name Phone .. <br /> Address` 1 _ � _. City : _ ". <br /> Contractor's Name License p .� Phone <br /> l� 7 3'f 1 �1 -71w <br /> TYPE-OF WORK (Check): NEW WELL /-7 . DEEPEN /H .RECONDITIONJ`/� ' DESTRUCTION �n <br /> PUMP INSTALLATION / J PUMP REPAIR /�_PUMP REPLACEMENT J j j <br /> Other /7 ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTTER <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 Drilled Dia. of Well Casing Domestic/public Driven Gauge bf-Casing <br /> •Irr'igation ,, Gravel ,Pack. . 4 Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - ` <br /> -� Disposal Other -Other Information /IZt4c)C <br /> Geophysical SurfaceSeal -Installed By., <br /> .,• _ to - . >», _ ., �y ., k_._ <br /> PUMP INSTALLATION. Contractor' <br /> Type of Pump <br /> -`r- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR. wp� F ,L7 _ State Work Done: <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth ~ <br /> Describe Material and Procedure <br /> I hereby agree to comply• with all laws and. regulat3ons of the San. Joaquin Local Heal•th .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 'putt'ing..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 /> SIGNER TITLE _ <br /> •(DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' .'F R D TMENT USE' ONLY - <br /> PHASE I � � � "� , .. .. . .. .. . ba <br /> APPLICATION ACCEPTED BY DATE10 <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT..INSPECTION. . PHASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE„_ ._.. . ._.. INSPECTION BY t..Q.'.C�/ -DATE. <br /> 1 ,E S 1426. w».Rev. 1-74� <br />