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&_ Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO-S OFFICE USE: 1601 E. Hazelton Ave. ,_&ockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -3-7 <br /> (Complete In Triplicate) <br /> Application is hereby made 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 Joaquin <br /> County Ordinance-Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> IE:a <br /> JOB ADDRESS/LOCATION :, . , .... . r `� ,., . , ". <br /> /"� CENSUS TRACT o.Sl-1 40-Z k <br /> Owner's Name Phone <br /> �p <br /> Address ', City F <br /> Contractor's Name ', "�'`r�: !"•- �se Phone3j, FW'2.Z <br /> TYPE OF WORK (Check): NEW WELL /_,T—DEEPEN '/_7 RECONDITION fj DESTRUCTION f_7 <br /> PUMP INSTALLATION PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other /_7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing /77- <br /> Irrigation <br /> 1'. .— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 9 _3 I Ed- <br /> Disposal Other Other Information Al <br /> Geophysical Surface Seal Installed By, - -- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: /7 State Work Done <br /> DESTRUCTION 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..ihe..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 GROUTING AND A FINAL VOECTION. <br /> SIGNED '` `_ "'t` -,,�°. TITLE. <br /> DRAW P OT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> TPM&LROUT IN3FECTIO P S IIF AL INSPECTION <br /> INSPECTION BY DATE �/ 7-�� INSPECTION $Y DATE / <br /> E H 1426 Rev. 1-74 lt/75 2M <br /> r <br />