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` SAN JOAQUIN LOCAL HEALTH DTSTRICT <br /> FOR OFFICE USE: 1GOl E. HazeltoZnrAve V'AY: S'toc'knrl -Calif <br /> Telephone::ir..:(20)`::4.661.6781 <br /> APPLICATION FOR WELL :CONSTRUCTIONI:OR PUMP PERMIT Permit No. 72— -7�3 <br /> A11 `IssuedYEAR� FRor -DITEI9UEIc ":D&te 'THis PERMSI +EXP3RES; °'Z 7 <br /> (ComleJtc? Ii `tTipcate) r,,f .. z t t, {2_ d3��3�f; ; <br /> i4pIicat on bid harebyxmadeito bheoSangJ6aquin LoLa'1 Rjialth District`.fb-r �aapermi.t tb`rcbnstc <br /> and/or install the work he described. This,appllcar drn'4is`-made:in- compliancei,Wi:th•,,San�f3,6aquin , <br /> r C!ounty:)Qrd nahcen1jo-.q1862x;and;;th4r}R�up11e&oan+dr;Reg` ul'attons 6E6the,Sam:xJoaquiw Local`Health":DisCrict <br /> ppp/ i <br /> - ..�[;� <br /> IJOB ADDRESS/LOCATION l"i� I --- ' CENSUS TRACT <br /> --emsL i, l fiS <br /> . <br /> '�jN ajl] i i3� 'n T(,, _I <br /> Owners -- <br /> Addressul <br /> Contractor's :Name „-^^ � _.__ ►� License ���q- Phone <br /> TYPE OF WORK (Check_.. .:....... . . .. . <br /> ) : NEW WELL;"/H DEEPEN / / RECONDITION DESTRUCTION <br /> PUMP.. <br /> INSTALLATION PUMP REPAIR /�/ PUMP REPLACEMENT / <br /> _ <br /> DISTANCE TO NEAREST. 'SEPTIC' TANK" '. SEWER LINES PIT PRIVY + + �- <br /> $K$.AL...FIELD.,. CESSPOOL/SEEPAGE PIT... OTHER. ` <br /> INTENDED...USE- <br /> TYP <br /> E OF WELL : CONSTRUCTION:SPECIFICATIONS <br /> .. Industrial.,.- ...Cable .To.ol Dia....of. .Well..Excavation -. .� . <br /> Drilled Dia. of Well Casing fJ <br /> Domestic/private; .. .. ..- ... <br /> • <br /> g <br /> t .. . , . . <br /> Domestic/piibl c Driven Gauge of Casing <br /> rra gatian.:. � . . ravel <br /> :.Pack.. out :SealTyp .Other Rotary pe of Grout - - -C <br /> { <br /> J <br /> Other Other Inforutation <br /> - �Tj <br /> PUMP IN i .. .. .. .. <br /> STALL.4TIoil Contractor ` <br /> Type ..of. Pump. P H.P-. '. <br /> PUMP REPLACEMENT:.NT;� . <br /> - SI' tate-Work Done � ... . ... . .. ...... ... i. N <br /> - - <br /> PUMP REPAIR' / / State Work Done <br /> .DESTRUCTION .OF WELL::.. . .-..Well Diameter. Approx a Depth . - - i-_ <br /> im te. <br /> : Describe Materialand Procedure <br /> I hereby agree .to...comply..with.al.I .laws.. and regulations o£ the. San.Joaquin Local xealth-District <br /> I and ,•the State of California pertaining to or regulating well construction. Within FIFTEEN;DAY <br /> after complexion of; tny work on 'a new well, I will furnish the :an Joaquin Local HealttiI3istric!t a <br /> Y g e...above. <br /> WE L DRILLERS, REPORT. _of• the well..andynotif them before .putting -the well in use. <br /> ... <br /> d e. and belief <br /> �nf ;rmation is true, to the best;of :m knewle : ., . : . . . <br /> SIGNED <br /> ;TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ;FOR DEPARTMENT USE ONLY <br /> PHASE I _.:.. ...;.. . i <br /> DATE <br /> APPIiICATION ACCEPTED BY <br /> ¢- <br /> COMMENTS: : <br /> ,.. <br /> PHASE II GROJT -INSPECTION P ITI/FIN INSP I { <br /> HAS AL ECT ON <br /> INSPECTION. BY - DATE INSPECTION BY DATE <br /> GALT; FOR A GROUT: IN PECTION-,PRIdR_TOw-GROiITING,AND FINAL.INS_._... TION..,_,_;.._.. M._ m_. - <br /> -- 5�.�.._ 4/72 1M <br /> E H 1426µ^_. t ...�.�. � ,. � <br />