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SAN JOAQUIN LOCAL I1EAZTF DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton:Aver.O St(� kton, Calif. <br /> Tel:eph_one: :.:.(20_9)- 466:67181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �"-.���(i��y �f <br /> F w{- r v• - .s rs fS.: .... ;i;.171_r rt uo (i-? .:c.lj.,t>37R •mow's. `.'=a .^: c_...%. ry � c:�l� 7S1f !�1 +.°i <br /> THISAPERNII EIIRES 1=,YEARFFtRO'4:,Dt1iSSUED; :�=�c�Date,. ssued.r zd T3� <br /> lf►xIri�li ate))t z : <br /> Application is hereby made to-the San:Joaquin�aLacal;;Yiealti erD strict far arspesrmitato .cofistruct <br /> 2nd/or a pplEi:cati:dn:il ,.uEade>.in compliance' tiiithr,5atti:�ciaquin <br />:County Ordariancecallos.,d1:862.rsand'ot4esRulesland ciRdgulAt ons'.ofnthe4�San-Ja'aqu n-Loca dHe_althZ strict. <br /> S-f!3f)c <br /> JOBe ADDS"f�ZOpp ;ACJi :ra13 .a E.. _ rCENSt3SSTRACT zc� sr a�.�X <br /> L+ .E. YE., 3#'x�`t €i �' :$.,E.`rii (i`7 ,T,a; ;erirJ i3;q a?: .i. Y_l t'�E�;�,. no mf Tp-�c .�k.�( ;_�: <br /> ... <br /> Owner's Name �lp L o Phone - <br /> Addresst.y <br /> Contractor's Name.. +�cle,.:. License # Phone; 23 <br /> ,tjE <br /> , . <br /> _TY WORK ;DESTRUCTION. ]WWELL <br /> : PUMP iNSATION, / � <br /> / PUMP REPAIR'/�/ PUMA.' REPLACEMENT. <br /> Other.. <br /> DISTANCE TO NEAREST: SEPTIC' TANK .. SEWER LINES PIT PRIVY <br /> t SEWAGE 'DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT : .-- OTHER <br /> Industrial ! SPECIFICATIONS E <br /> INTENDED USE TYPE OF. WELL ' CONSTRUCTION Cable Tool Dia. of Well Excavation SPE <br /> Domestic/private: "IDrilled' Dia. of Well Casing r7 <br /> Domestic/public, ... T <br /> 1 Driven Gauge' of; Casing a + <br /> Irrigation �' Gravel Pack h ' . Depth of: Grout Seal <br /> OtherRotary Type of Grout <br /> t Other . ..Other Information.`,. <br /> PUMP INSTALLATION: Coiltr�Lctor <br /> H:.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> PUMP- REPAIR: /=/ State Work Done <br /> d <br /> DESTRUCTION OF WELL: Well Diameter Approxitnate Depth --� <br /> Describe :M-at erial and P'�5cedu�'e <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 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 `knowledge”and belief. ' � <br /> r <br /> 1 <br /> SIGNED f TITLE : eet- <br /> F (DRAW PLOT PLAN ,ON REVERSESIDE) OF <br /> Nf <br /> 7ORL DEPARTMENT USE ONLY ` <br /> PHASE I : ... DATE 7- 2: <br /> APPLICATION ACCEPTED BY! <br /> ADDITIONAL: COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE I I/;FINAL INSPECTION ' <br /> INSPECTION BY DATEj►- <br /> INSPECTION BY DATE _ 7+� a -�� _ .....,_.. ._ ._... .... .r-.W_....__ ._z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 <br />