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SANtJOAQUIN:LOCA ;--HEALTH ISTRICT —--— 1 <br /> FOA:OFFICE USE: 1601 E. Hazelton Ave., Stockfbg, <br /> Calif. <br /> Telephone: (209) 466-6781` / <br /> APPLICATION jOR_.WELL !ONSTRUCTION aR PERMIT Permit No. 7 In <br /> ,Vp�X1AA THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue(Complete In Triplicate) <br /> Application e y made to the San Joaquin Local Health District or a permit to construct <br /> and/ nstall the work herein described. This application is made icompliance with San Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaqu Local Health District. <br /> JOB ADDRESS/LOCATION ALCN6 C&u e)ivVCP 4)eT-d -( CENSUS TRACT <br /> Y <br /> ,�` ,�oiV6 t=,ru,�Xo•�n� �jni,�rat!Y�i�s. <br /> Owner's Name rr 1u Phone - 73 79 <br /> Address UJ d oCce 1►f, City i.v,9 <br /> Contractor's Name .; e r n e o h 1 e License # Phone ( G a-6 6 9/ <br /> TYPE OF WORK (Check): NEW WELL/FrDEEPEN /—/ RECONDITION /7' DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT /7 <br /> Other / J -- •,, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ,- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL J'J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing MIA <br /> Irrigation g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �Rotary Type of Grout <br /> Disposal Other Other Information c. <br /> Geophysical 'Surface Seal Installed By: , { <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ;� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ;REPAIR: /? State Work Done J <br /> E&TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AND A FINAL INSPECTION. <br /> SIGNED TITLE -19 r <br /> nq <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEMTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED B <br /> O�''� � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION By DATE INSPECTION BY DATE <br />`� E H 1426 ev. 1-74 _l - �:o_ _ ��.� /i�,;r�� - <br />