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41. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1-601 r,_ Hazelton. Ave. s Stor.;.'�:on, Calif. <br /> Telephone: (209): 466-6781 Cf�� <br /> APPLICATION 'FOR WELL CONS'TrIJCTION`OR PUMP PERMIT Permit. No. - ,9.6 <br /> THIS PERMIT <br /> EXPIRES 1 YEAR FROM DATA; ISSUED Date Issued �V1 - <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 aridrthe:Rules and Regulations of%�the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,�IF.� A1�� _�C 1 ��,IV L L� /1� _ -- CENSUS TRACT <br /> Owner,s-Name"i - � Phone <br /> Address -3 0 . lS� ✓ AL F 0 170 City S 7-0 6Ir1f G/Af <br /> Contractor's Name ,( --{ ` 1. i 17Q4211--?C6ticense # 74 'Phone S�CZ-•�_�� <br /> TYPE OF WORK (Check) : NEW WELL -_& DEEPEN/ / RECONDITION /_/ DESTRUCTION /�T <br /> i PUMP INSTALLATION PUxiP REPAIR -I I PUMP REPLACEMENT /_T <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK 2.5r SEWER' LINES PIT PRIVY- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t <br /> Industrial Y" :� Cable .Tool Dia, of Well. Excavation <br /> Domestic/private Drilled Dia. of �Well Casing <br /> i Domestic/public Driven Gauge of-Casing <br /> Irrigation Gravel. Pack Depth .of Grout Seal <br /> Other - _X Rotary Type of Grout T <br /> t Otlier + Other Information <br /> PUMP INSTALLATION: Contractor I if co <br /> f - Type of Pump H.P. <br /> i F <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: / / ' State Work Donee. h <br /> ,DESTRUCTION OF WELL: Well Diameter - .„» Approximate Depth_ <br /> - Describe Material and Procedure i <br /> I hereby agree to comply with all laws and regulation`s 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 /> I, information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED ' ' ' <br /> RAW <br /> PWT PLAN ON REVERSE SID <br /> DEPARTMENT USE ONLY <br /> PHASE .I. . <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: Mw. <br /> PHASE II GR S TI PHA I IJFI INSPECT 0 <br /> INSPECTION BY :77*`DAT INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> 4/72 1M <br /> E H 1426 <br /> Y <br />