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SAN JOAQUIN_,L0CA%-,1EALTH DISTRICT <br /> FOA!OFFICE USE: 1601 E. Hazelton Ave:, : Siockton, Calif. <br /> Telephone (209) .-466'-6781 <br /> APPLICATION FOA'WELL CONSTRUCTION OR PUMP PERMIT Permit No.7.- <br /> THIS PERMIT_EXPIRES­ 1=YEAR 'FROM, 'DATE"T'SSUED, .'Dafi I6sued <br /> (Complete In :Trip/ j k <br /> Application is hereby made to the San Joaquin,..Local 2ealth Fllstrict`for''a permit to construct ' <br /> and/or install the work herein..described.. ..-This applicationiis:,made iir-compliAnce with -San Joaquin , <br /> County Ordinance No. 1862 and the Rules_ and Regulations of.-,the..San<.�Joaquin.Local'Health'District. <br /> JOB ADDRESS/LOCATION 3 ENSUS'TRACT <br /> .yam. <br /> Owner's Name Phone <br /> Address,�z:" -City , <br /> ...��..r. . _ ._. .r-- ., ...._.. l .S'V'Z <br /> Contractor's Name ! License # k Phone 'q.)7� <br /> TYPE OF WORK-.(Check-) NEW -7- DEEPEN- RECONDITION /7 DESTRUCTION _f_7 <br /> PUMP INSTALLATION / / . PUMP REPAIR / / .. PUMP. REPLACEMENT /7 . <br /> Other '/—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC'WELL' ' PUBLIC DOMESTIC WELL 4', <br /> INTENDED USE TYPE OF WELL „ CONSTRUCTION SPECIFICATIONS. <br /> Industria] k' Cable Tool Dia. of Well Excavation <br /> Domestic/private . --Drilled Dia.. of Well Caging y4`1 <br /> Domestic/public Driven Gauge of Casing , <br /> __.X..- Irrigation Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection -Rotary Type of !Grout ' <br /> Disposal Other ., Other, Information. <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor :a <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: Ll State ,Work Done ' <br /> / / State Work Done <br /> PUMP�:�REPAIR: <br /> s <br /> ES'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descxibe--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 !sell 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 .!sell in use.. The above <br /> information is true to the'beet of-my knowledge-and belief._ I :WILL CAI;L FOR 'A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL -INSPECTION. <br /> SIGNED t TITLE <br /> -(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I f <br /> APPLICATION ACCEPTED B / ! DATE 9r <br /> ADDITIONAL COMMENTS: .144C_ A-4 <br /> PHASE II GROUT INSPECTION PHAS III/FNAL INSPECTION,. <br /> INSPECTION BY BATE INSPECTION BY DATE 1' <br /> E H 1426^ Rev. 1-74 1-74 2M <br />