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- <br /> �F SAI>I JOAQ[3IN LQG.?L HEZALTH DT STRICT , ` <br /> 'T F OFFICE USE: 1601 Ell }laze A.ton Ave. , StoclzZ,,,-. , Calif. <br /> Telephone: (209) 46-6-67131. <br /> G PLICATION FOR WELL CONSTRUCTION OR PL:�[P PERMIT Permit No. - 37 <br /> THIS PERMIT .EXPIRES 1 :YEAR FROiz ;AT',1 ISSUED Date Issued S a- <br /> ' <br /> (Complete 'In Triplicate) <br /> Application is. hereby made to the San.Joaquin Local Health District for a permit to construct <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 /> jti <br /> i JOB ADDRESS/LOCATION CENSUS TRACT <br /> tti��- trS S7 U <br /> Owner's4.Name,.s 'Phone !2412 7-0 / <br /> Address <br /> City s z/C/v <br /> � f s- - . <br /> - _ <br /> License # A7 Phone <br /> [ [ �3a� <br /> Contractor s Name il 7YA,4( � <br /> TYPE OF WORK (Check) : NEW WELL 'Ly/ DEEPEN / I RECONDITION /_� DESTRUCTION I�T <br /> PUMP INSTALLATION / J PUMP 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 /> Industrial Cable Tool Dia. of Well Excavation `' 4; <br /> Domestic/private Drilled Dia. of Well Casing 1' <br /> Domestic/public Driven Gauge of Casing <br /> J <br /> Irrigation - Gravel Pack Depth of Grout Seal S'O <br /> Other i }� Rotary Type of .Grout <br /> s <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor -� y6/ <br /> kType of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / 1 State Work Done <br /> PUMP REPAIR: �'- - / / State Work Done <br /> w <br /> Approximate Depth <br /> .2ESTRUCTION OF WELL: Well Diameter pp p <br /> Describe Material and Procedure <br /> ' I hereby agree to comply with all laws and regulations of theSanJoaquin 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 f <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. my'knowledge and belief. <br /> TITLE- <br /> -(DRAW PLOT PLAN ON REVERSE SIDE) <br /> j F R DEPARTMENT USE ONLY• . k <br /> PHASE -I � .. - � ._ m , _ ..__.. . DATEZZ� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE II JFINAL INSPECTI N <br /> "NSPECTION BY DATE a 1 INSPECTION BY DATE �oZ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 lM <br /> It 1426 C ., <br />