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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stacicton, Calif. <br /> FOF'0..FFICE .USE: Telephone: .(.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13- T2® <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ,ISSUED <br /> Date Issued 3 <br /> (Complete In Triplicate) <br /> Application is hereby made t the San Joaquin Local Helton istrict made inra permit comp construct <br /> Apel application <br /> and/or install the work herein described. ' This app 22?— omae off <br /> Count Ordinanca :No. 8b2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County T � <br /> ,✓CENSUS 'TRACT <br /> JOB ADDRESS,_0 ON <br /> Phone •J <br /> Owner's Name N <br /> City <br /> Address <br /> License <br /> / w Phone Q <br /> '? . ��� � <br /> Contractor's Name <br /> IWORK Check): NEW WELL/ J DEEPEN / I RECONDITION / pESTRUCTIONUMP REPLACEMENT�/� <br /> { TYPE OF ( PUMP INSTALLATION f / PL'i�iP REPAIR'/�-� ' <br /> f other/ / <br /> 4PIT PRIVY <br /> DI TS A CE TO NEAREST: SEPTIC TANK SEWER LINES OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT L1 <br /> INTENDED USE �TYPE.'OF-WELL , <br /> CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> t Industrial :,., Dia: <br /> �. rivate ` -Drilled_ of Well Casing <br /> Dom�sric'/p Driven Gauge of Casing <br /> f Domestic/public a <br /> ` Gravel Pack Depth of Grout Sea] <br /> Irrigation Rotary Type of Grout <br /> Other Other � Other information � C <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT1. /,/, -State Work Done <br /> State Work Done COO <br /> PUMP TtEPAIR: <br /> Approximate Depth <br /> DFQTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> ca <br /> lEh <br /> rict <br /> I hereby a;ree to ccsinply with allinin$ todoreregulatingulations af the Sanwell "construction.LoWithinaFIFTEENtDAYS <br /> and the State of California pertain <br /> g fi= <br /> well, I will furnish the San Joaquin Local Health District <br /> -iter completion of my work on a new <br /> a• WELL DRILLERS RLPORT of the well and notify them before putting the well in use. The above <br /> information iS true--to-the s't:of my knowledge and belief. <br /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> � ,ra <br /> APPLICATION ACCEPTED .BY ( ' <br /> ADDITIONAL COMMENTS: I/ NAL INSPECTI N <br /> PHASE II GROUT INSPECTION INS DATE <br /> INSPECTION BY DATE <br /> CALL k'OR A GROUT INSPECTION PRIOR TO GROUSING AND FINAL INSPECTION. // <br />