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SAN JOAQUIN LOCAL.HEALTH DISTRICT - -- <br /> PWOFFICE USE; 1601 E. Hazelton.Avee ,!=Stodkton, Calif. f <br /> Telephone:2 `,(209) 466=67,$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 75 7 7t, ` <br /> THIS PERMIT ;EXPIRES, 1-YEAR-FROM,DATEJSSUED '-Date Issued <br /> ,.R,• F,•.;�„ � $, , ," ��.{�F4� );�•,4:°. ,: �(Comple,tesla.Trip�.�.cate) �. �_ :� ,. ' xi •� H_t�.° � -r. µ:= <br /> Appli6ation ie hereby made to the San Joaquin;Local.-Health .District:-fox a pexmit to,construct s <br /> .and/or install-the ,work, herein described..,'.'This ,application�,is made in,- compliance with�San Joaquiim <br /> County'„Ordinance. No `;;1862,,and the .Rules�and_:Regulations: of -the;,,Satr Joaquin;Local Heal ih.:Disti:ict. <br /> JOB ADDRESS/LOCATION Q: �� (,t/ , CENSUSiT'RACT w y, k 1 !L, <br /> 1 <br /> Owner`s�Name Phoned S- <br /> Address /:'. _ o-. .., ._�... .�� R _. -City `•: <br /> m � i <br /> Cofitractor'6.Name . { • y License kfk Y Phone <br /> s <br /> TYPES OF WORK (Check) :F- NEW WELL /ZT-___DEEPEN:'/_7jRECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR /-7 ; PUMP. REPLACEMENT <br /> Other <br /> k r � I <br /> DISTANCE TO 1NEAREST: = SEPTIC TANK - SEWER- LINES , PIT PRIVY <br /> ', SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT; OTHER 3 <br /> }” PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (yam <br /> INTENDED USE. TYPE OF WELL S ;CONSTRUCTION1.SPECIFICATIONS <br /> Industrial' { ale Tool. Dia. of -Well Excavation. >.9 - <br /> 7-n—mestic/private Drilled Dia. 'of Well Casing ��"" ^� <br /> Domestic/public« Driven Gauge of Casing. 1_9 ',9 . <br /> Irrigation Gravel Pack Depth of Grout: Seal <br /> Cathodic Protection s Rotary. Type .of Grout <br /> Disposal Other Other Information <br /> Geophysical. L Surface Seal Installed By: <br /> PUMP INSTALLATI6N:3 Contractor <br /> ` Type of 'Puttp H.P. ,... ...�..�. <br /> PUMP REPLACEMENT: State Work.Done; <br /> PUMP `.REPAIR: 1 .State Work Done` . <br /> PES kUCTION 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 furaish 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 TWILL •CALIF FOR A 'GROUT :INSPECTION <br /> PRIOR TO GRO ' i G AND A FINAL INSPECTION: <br /> SIGNED TITLE; <br /> DRAW PLOT PLAN'ON' REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED' BY >� DATE -Z ` <br /> ADDITIONAL COMMENTS.: <br /> x ' �PHASE -IIIGROUT INSPECTION PHASE TII /FINAL INSPECTION <br /> INSPECTION BY /,: _ DATE -/ ] -INSPECTION BY DATE <br /> - <br /> 1 '1 E H 1426 Rev. 1-74 ' 1-74 <br />