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/0 lea <br /> a 11 /VyJr/Y/ SAN JOAQUIN FOCAL HEALTH-DISTRICT . <br /> COL OFFICE USE: 1601 E. Hazelton Ave. , Stodktoh-, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. j'� <br /> ,, THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 -a S-7th <br /> SII .. - (Complete In Triplicate) <br /> Application is hereby sft'ade '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 J,baquin� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local }iealth Disprict. � <br /> i <br /> JOB ADDRESS/LOCATION iI 66 1! CENSUS TRACT , <br /> Owner's Name <br /> Phone <br /> Address 6 Cit <br /> Contractor's Name License Phone —7G7,1 <br /> TYPE OF WORK (Check): :NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /7 <br /> `PUMP INSTALLATION / PbW REPAIR ,/ // PUMP REPLACEMENT 'K7 <br /> "Other '/ / <br /> d <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 Cable Tool Dia. of Well Excavation <br /> Domestic/privatJ� Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation i Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> II Other Other Information <br /> 'UMP INSTALLATION: Pontractor <br /> Type of Pump 'Aja H.P. ' �p <br /> PUMP REPLACEMENT: State Work Done eg,Akl <br /> PUMP UPAIR: ;/ / State Work Done . . . <br /> ;DFgTRUCTION 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 /> infor terra s true to the best of m k ledge and elAef.. <br /> SIGNs /)� _ ITLE <br /> y __ D ., W OT PLAN ON VERSE SIDE) <br /> q <br /> FOR DEPARTMENT' USE ONLY <br /> P�iAS0 I. ii / t <br /> APPLICATION ACCEPTED .BY! . / DATE - ( - <br /> ADDITIONAL COMMENTS: <br /> 76/ <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTION <br /> INSPECTION BY it DATE INSPECTION BY DAT <br /> -CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> .E,.H,. 426 i! .. <br />