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k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton.'Ave:'-'(S' ockto--,., Calif. <br /> Tele.phone::�_::(20�)'�4fi6�6781 • <br /> APPLICATION FOR WELL CONSTRUCTIONr40R PUMP PERMIT Permit No. -Y,'-5' V <br /> THIS PERMIT ;EXPIRES,7l YEAR IFROMaZATEL41S'SUED -°_ > 'J'rD.ate`Issued; Jam- <br /> ':R- -1. _3 <br /> Ii3zT ipl E~a e} `ars 1rIV <br /> v rr,.tr; i.; :;. ; i .;fr i' <br /> Applicatitoriai!,)hereby-madei o theoSanr;J6aquin-:Lo6a1 Healh- F. <br /> and/or install the work herein described. Thig-capplicat on4s 'made-`1n,;comp1Tijatcef with F-San 1-oaquiri: <br /> t <br /> County r_jOrdinanceoNo <iS62r:sand*.theRuxesand'"rRegultcsns'oftYe.:5an=Jf6aqun�-Loca1> Hea]tR'=Datricts <br /> _3.� .�:i; L?� ,�':3. :aC;a ?j Fn .f{: rf:!r�`rs'.^? `�:wtS�C�?f'.. ,.,�:',n✓a. :�t.. P?�,f..;?.- :e: .5 �.,�.r'.C;,i74:-:�i�, .31�i:�l;t�L .f._>:-.t.•ryi3.i. <br /> JOB ADDRESS/LOCATION hi, Ac aft ANO.;,lk,,CENSUS,,,.TRAC.T"�,�' =a-rsr.r <br /> �,�3rt!:t�.{<>•.fi� ja7 'I3SU���F; `:l� " �'�°:i 3 ET? � f{ dkC �• � ` i✓ r d! � l.ifi� .ve?�`. ei:;r ' v .k.tJ r1;..fir '��. w^r;�:. <br /> { Owner's aNim40 t..1E �., t ° �r r;(r k �7d3 ! ? Du .1 ka�'.1'� :.7e,a:,PhoAC <br /> Address <br /> Contractor's NameId- AkCf License # Phone ' <br /> R43 -cS-12l.3 <br /> TYPE OF WORK (Check) : : NEW WELL'' DEEPEN '/ / RECONDITION /? DESTRUCTION /7 • } <br /> _ - PUMP-INSTALLATION % / _PUMP,-ItEPAiRT/�-/ ' PUMP--REPLA-CEMEN-T-.-�/--7 . <br /> s <br /> Other; <br /> DISTANCE TO NEAREST: SEPTIC TANK, '. SEWER LINES . PIT PRIVY .� <br /> a <br /> SEWAGE- DISPOSAL-FIELD —� -`. CESSPOOL/SEEPAGE�PIT., OTHER: <br /> INTENDED U•SE' TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial- : Cable Tool Dia. of Well Excavation <br /> `A.;;�-^ Domestic/private: Drilled Dia, of Well Casing <br /> Domestic./piib is Dtiven i Gauge' of` Casing - <br /> Irrigation. GravelPack Depth: of Grout :Sea1 �,+p <br /> Other , Rotary .' ; Type of Grout <br /> Other Y Other: Information <br /> f PUMP, INSTALLATION; Cohtractor p:a;C <br /> # Type of Pump oYr s 4 r �. H..P. <br /> PUMP. REPLACEMENT: � . / / State Work Done � <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: . . .Well Diameter Approximate Depth <br /> Procedure _ <br /> I hereby agree to comply with -all laws and regulations of the San -Joaquin Local Health Mm District <br /> anal 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 /> F 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 /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON .REVERSEiSIDE) , <br /> i <br /> :FOR ,DEPARTMENT USE ONLY } <br /> ' PHASE I ; <br /> APPLICATION ACCEPTED BY �` �� - - �' DATE -7 "�t7 <br /> ADDITIONAL COMMENTS: <br /> I <br /> PHASE GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE �,.2G '� � INSPECTION BY ^ DATE //�./ -� 31 <br /> CALL FOR A GROUT' INSPECTION PRIOR•_TO GROUTING AND FINAL INSPECTION. <br /> E. H 1426`. - - - 4/72 <br />