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SAN JOAQUIN LOCAL HEA1,TH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton"Ave. .' - St-ockton, Calif. <br /> Telephone: .(2019).,,-46:6-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION."OR PUMP PERMIT Permit No. 7 J 40 0 <br /> THIS PERMITrEXPIRES%.-11,YEA­R4TROY1,DATE :ISSUED'­ Date Issued- LF-/--72_ <br /> 7 <br /> ;)Iti (Complete IiVTtip)idat&) 15,V673 <br /> Application is -.hereby-made`.Ito the(.,San r�Joaquin :L66al Health, District for,.,a permit' to coristrVbt <br /> .,and/or install the work herein described. This-,application,is--made incompliance- with San Joaquit <br /> . 0 <br /> County Ordinan"cec.No.,: .1862i:Znd-,�thd-Rulegl��and-Regulatioris' if -'the ,San 'Joaquin Local-Health District;. <br /> JOB ADDRESS/LOCATION M u ll rc t-d CENSUS:TRACT <br /> ,0c <br /> T . r <br /> to X-,I­_Wo7q r.';j 4o .1"v— r'; I f= W. il.­ <br /> Owne ,,'i-Phone: CX.,.©r�;6 N-am6�`T, <br /> Address 'a4".A le City. <br /> Contractor's Name 'gel License ,#. _Aone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '&f�RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 'PUMP REPAIR '/ / PUMP REPLACEMENT_ <br /> Other <br /> .�,- DISTANCE TO NEAREST-: SEPTIC T4KTSEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOT)L/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> "Domestic/public Driven Gaugeof Casing <br /> Irrigation Gravel Pack Depth%of Grout. Seal <br /> Other Rotary Type of Grout <br /> Other Other inf6rmation <br /> PUMP INSTALLATION: Contractor <br /> Type' of Pu <br /> A4 H.P. <br /> %7 V <br /> �UMP REPLACEMENT: State Work 'Dane eU4-,LX 4ekt /C on . <br /> PUMP REPAIR: State Work Done <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 /> after completion of my work'6n 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 rue to the best .of my knowledge and belief. <br /> SIGNED TITLE <br /> ZV (DRAW PLOT PLAN ON REVERSE SIDE) <br /> V FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ff1/72_ <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT: INSPECTION PHASA III/FINAL INSPECTION <br /> -Lvil <br /> INSPECTION BY I DATE INSPECTION BY DATE <br /> -7 <br /> CALL FORA GROUTN <br /> INSPECTIOPRIOR TO GROUTING AND FINAL--INSPECT ON. <br /> E H 1426 4i72 lm 1 <br />