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a <br /> .�.,. � SAN JOAQUIN LOCALHEALTHDISTRICT <br /> � <br /> FpErOFFiCE USE: 1601 E. Hazelton `Ave: ,`xSt.icktan, Cali � <br /> Telephone:- <br /> -(2;9) 466-6781 <br /> APPLICATION FOR WELL CONSTR66TION OR PUMP PERMIT Permit No. C I' <br /> THIS PERMIT <br /> ,EXPIRES 1#YEAR=FROM DATE ISSUED Date issued <br /> (Complete In.Triplicate) <br /> Application is hereby made to the San Joaquin :Local-,-Hoalth District for a 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: ofs.the San Joaquin Local Health District. <br /> - - <br /> i JOB ADDRESS/LOCATION CENSUS TRACT - <br /> J Phone - ; <br /> Owner's Name <br /> l _ f�, City ��� <br /> Address <br /> License Phone <br /> Contractor's Name.. <br /> z � . s��- <br /> TYPF. OF WORK (Check) : NEW WELL % DEEPEN I�T RECONDITION / T DESTRUCTION / <br /> PUMP INSTALLATION X PUMP REPAIR /7 PUMP REPLACEMENT /? <br /> ' Other / // <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES / ) PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE . PRIVATE-DOMESTIC WELLPUBLIC DOMESTIC WELL - <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well. Excavation / y' <br /> 1 Y' Domestic/private Drilled Dia. of Well Casing <br /> .Domes t-ic/publie — Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of .Grout <br /> Disposal <br /> Other Other Information <br /> — <br /> � Geophysical. _ Surface Seal Installed B n� � <br /> .. to <br /> PUMP INSTALLATION: Contractor NA119a ld&& 44R <br /> Type of Pump � H.P. <br /> PUMP REPLACE1 M / / State Work Done � <br /> -'PUMP rREPAIIta"� �� -- T:' Work Done <br /> � ES�'ERUCTION OF WELL: Well Diameter <br /> Approximate Depth i <br /> Describe Material and Procedure <br /> I hereby agree ' comply with all laws and regulations of the San Joaquin Local Ytealth 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 Districta <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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION., - ._.4 , <br /> �. SIGNED � TITLE <br /> -(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I DATE / 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4VDATE t r 7,------- <br /> 7 <br /> '1-74 2M <br /> t � E H 1426 Rev. 1-74 <br />