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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> on <br /> —FOR�'OFFICE .-USE: /� 601 E.. Razelt -.:Ave-. ,;_96' kfon, Calif.oc-678V- <br /> Telephone: ,,-(209) <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. <br /> THIS rPERN1T,EXPIRES 1. EAR FROM--DAT- <br /> .(Complete.,-1n,,,,Triplicate) <br /> or, <br /> Application is he I ieby made t)§ the San Joaquin Local -Healthy District f ' -a.: pe-rmit:_to.,donstruet <br /> and/or install the work herein described. ,. This._application '.iis ,,made-,:in., compl-iance with,,. San Joaquin <br /> County Ordinance No. 1862 an,d the-Rules and Regulations of the,.�San, Joaquin Local l-Health',Dis trict. <br /> (CENSUS ADDRESS/LOCATION;. <br /> A <br /> Owneifs� Nam I A Phone f, <br /> 7 k: <br /> - <br /> f Licens # --Phone gak,� �A_26 <br /> -Contractor s Name e LN 71Z <br /> TYPE OF.WORK (Check): -NEW -V1ELL -ZX7,-' DEEPEN /7 RECONDITION /_7' - DESTRUC'f-ION /7' <br /> PUMP INSTALLATION J. <br /> PUMP REPAIR /7 Pump REPLACEMENT <br /> / <br /> PtheriLL/ -haQ--A QZO&— )420dA4 -01, 52L,�.42442IU4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT,PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPO.0L/SEEPAGE.PIT OTHER <br /> PROPERTYLINE —PRIVATE DOMESTIC WELI:' 'PUBLIC DOMESTIC WELL <br /> INTENDED USE . .TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,__. <br /> Industrial ,I It Cable Too! Dia. of Well Excavation <br /> X <br /> Domestic/private 4 Drilled Dia.; of,Well 'Casing'- " <br /> a <br /> Domeeticjpublic 11 Driven Gauge of Casing 42 to <br /> Irrigation I Giivel'--Packth of GrouOSeal' <br /> Dep' 11, <br /> ,- : N <br /> Cathodic Protection. Rotary Type�sof Grout- <br /> Disposal t_ Other Other,.1%iformation:.. <br /> 'Surface Seal Installed By. z7LtzLvi <br /> Geophysical , f 4'. <br /> . 4 <br /> PUMP INSTALLATION:, Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: S tate�Work_ Done <br /> ,.REPAIR: _7� ,-Work Done_ <br /> PUMP �IState <br /> PES,-TRUCTION OF WELL: Well' Diameter Approximate Depth <br /> . Describd 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 SanLjoaquin Local Health District a <br /> WELL DRILLERS REPORT <br /> PORT 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'I'VOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNED TITLE <br /> (DRAW PLOT'PLAN ON REVERSE SIDE) L <br /> jFOR DEPARTMENT USE ONLY - <br /> PHASE I uL-7 <br /> APPLICATION ACCEPTED .BYDATE /,Z a <br /> ,'- ADDITIONAL COMMENTS: .1 <br /> PHASE 11 GROUTiINSPECTION PHASF,I AL INSPECTION <br /> INSPECTION BY 1-DATE 'INSPECTION BY DATE <br /> E 8,.-1426 Re 1t74, 1-74 2M. <br />