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r *' SAN JOAQUIN,LOCAL slHATITH'DISTRICT <br /> 1` u, <br /> USLocktoa Lf.0FF1Cr ibUL P„ {aTelephone: (209) .466-6781 \- <br /> APPLICATION FOR,WELL' CONSTRUCTION OR PUMP PERMIT• Permit No. <br /> THIS PERMIT EXPIRES 1 .YEAR FROM 'DATE ISSUED � <br /> " `.. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District.fort-a permit'`to ,conistruct,' <br /> end/or install the work herein described. This application is made4n-compliance,-with�8aa"Joaquin' <br /> :. County Ordinance No. 1862 and the Rulao and-.Regulations of -the:.San,,Joaquin:,Local,Health •Distrf.ct. ..if <br /> k: _ <br /> / CENSUS o TRACT " . <br /> JOEL ADD 'ZIZ6 4'c��,�i^ci �� �3�(/ <br /> Owner's Name Phone <br /> Address ,� r City , <br /> a a <br /> r Contractor's Name License Phons. [i <br /> 1 TYPE OF WORK (Check)t NEW WELL gr DEEPEN /7 RECONDITION /7 DESTRUCTION r], s <br /> PUMP.INSTALLATION :,g .,PUMP. REPAIR L`7. Pw::REPLACEMENT �. *"i � ;`�A <br /> ' Other /-7 <br /> DISTANCE TO NEST:. SEPTIC TANK SEWER LINES PIT PRIVY � ; x R r €. <br /> ARE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS « . <br /> Industrial Cable Tool Dia. of Well Excavation 4"'.0,29,7 <br /> �• r <br /> ' Domestic/private Drilled Dia. of Well CasingSig <br /> Domestic/public Driven ; . Gauge of Casisig <br /> Irrigation Gravel,Pack �, Depth. of Grout Seal d *a <br /> .Other =Rotary` Type of Grout777.7, <br /> Other Other Information= ,a <br /> 5- F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumps.., ���� v H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> y ' { 4 <br /> PUMP REPAIR: /� .State Work Done # <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept <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 constructi.on... Within-.,FIPTE$CiAAY& <br /> after completion of my work on a new wellI will furnish the San Joaquin Local Health District a' <br /> WELL DRILLERS REPORT o e well and notify: them before.putting the well in use. ' The`above <br /> information is true o t e of m hedge pr.d belief. r ; r <br /> SIGNED ~ TITLE I ' <br /> DRAW FLAN ON REVERSE SIDE w, <br /> 14 , <br /> = FOR DEPARTMENT USE ONLY v y p <br /> PHASE I <br /> APPLICATION .ACCEPTED BY " r �--s �. � � DATE <br /> ADDITIONAL COMMENTS: J <br /> ..,p. PHASE II GROUT INSPECTION PHASE I INAL INSF ONy t � <br /> INSPECTION BY DATE _���».'1te INSPECTION BY DATE'. "96` 'd,-* <br /> x :. <br /> C;,-LL FOR A GROUT INSPF;CTION PRIOR TO GROUTING AND FINAL. INSP N. <br /> E H 1426 '4/72` lH <br /> _ � r <br /> - a. x">r:+ ;G„;. •...-..d- ;..... _ .� -:t,z .:sem: s .�, i ^F- � s k r <br /> X. <br /> 43 <br /> a �,F:�A.. .a•.i •ff4ry..4.W:.r3%- 4 <br />