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-„ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktox., Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 37 1664] <br /> THIS PERMIT EXPIRES 1 YEAR FROMDATEISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for 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 and the Rules and Regulations of t"an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .2 / CENSUS TRACT S `� <br /> Owner's Name Phone <br /> Address `- y2 -� / _ City <br /> Contractor's Name License # 2?/d oa Phone` ` <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ J PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial z.— Cable Tool Dia. of Well Excavation /y <br /> h Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal N <br /> Other Rotary Type of Grout QJ <br /> Other Other Information V� <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r, DATE 1,,2 -/ <br /> ADDITIONAL <br /> a-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY?" DATE /A. -��_�Z:2- INSPECTION BY 4E2 DATE 5f"-�J"- 3 <br /> CALL FOR X GR U I 5PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �' 4/72 1M <br />