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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 .F,. Hazelton Ave. , Stoclt: oaf, Calif. ,{ <br /> Telephone: (209)- -466•-6781 $ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT'EXPIkES 1', YEAk'FR0M..DATE ISSUED Date Issued <br /> (Complete `lii Triplicate) <br /> Application is. hereby made tolthe 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. 1.$62! and ..the Rules and Regulations of- the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION d'! CENSUS TRACT <br /> .' <br /> `Owner's Name,f4 «..�. JC �E`o..�1:/�'h _ - --- — Phone J <br /> Address d City . - <br /> Contractor's Nam "' License # /10-Ys� Phone 206 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR -,X/ PUMP REPLACEMENT /-7 <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 i Cable Tool Dia, of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing # <br /> Domestic/public I Driven - Gauge of Casing <br /> Irrigation 1. Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contr actor <br /> TYpe of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR: / State Work Done / �� �" <br /> / ! <br /> 41 <br /> ,DESTRUCTION OF-.WELL: Well Diameter Approximate Depth <br /> Describe 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 /> P g <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 putting the well in use. The above <br /> information is true to the best of my w1 ga an belief. <br /> SIGNED <br /> (D W PLOT n ON RE SE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� ✓ Er DATE g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYINSPECTION Me' pZgn,. D TE 'ZZ <br /> CALL FOR A GROUT INSPECTIO IO TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 4) <br /> 4� d <br />