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k pY � <br /> 1 T. .4 <br /> SAN JOAQUIN LOCAL I:%ALTH DISTRICT FILE C ! i%' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Sto,[kton, Calif. t` <br /> Telephone: (209) 466--6781 u <br /> / APPLICATION FOR WELL CONSTRUCTION OR PUMP PEMXIT ;Permit No. 71 %JP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date, Issued �� <br /> k M (Complete In Triplicate) <br /> Application-isok- <br /> hereby made to the San Joaquin Local Health District for a permit to coiistruct — <br /> j and/oriinstall the •--srk herein described. This applicationis made in compliance with San Joaquin':`.;: <br /> County',Ordinance,No.`1862 and the.Rules and Regulations of'-the/San Joaquin Local HealthtDistrir.t , <br /> .FOB ADDRESS/LOCATION F" / K,d CENSUS'TRACTw { � <br /> r Owner',s-.Name C �A fI ;:: �^ Phone . <br /> -_ J, <br /> , _ <br /> Address / ; - Irr ',('�' f f':r (,� .(."i ��.{_ i rf r City ��1`-r.% b * <br /> f Contractor's Name License (r. Phone �J' -y l <br /> >. ---•--'-r.: _ ----'—, _mesas `ry �6''�. <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN / / RF,CONDITION -C'L 'TRUCTION <br /> • "' PUMP INSTALLATION / / PUMP REPAIR PU�T REPLACEMENT <br /> d., t Other <br /> DISTANCE TO NEAREST: SEPTIC:TANK EfdER LINES _ PIT P <br /> SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE.PIT OTHER �K <br /> INTENDED USE TYPE OF WELL CG: i .TION SPECIFICATIONS , ` <br /> h Industrial Cable Tool Dia. of We l .ti:�5vation X"., <br /> Domestic/private. Drilled Dia, of I+c.il G:xaing - � �{: <br /> Domestic/public Driven gauge of Casing x ' ;=f'.yfk.. <br /> ,,Irrigation ' ' Gravel Pack DQpth of Grout Seal ^ <br /> t'Oifier Rotary Type of Grout, � ► <br /> Other Other Information T 4: <br /> PUMP INSTALLATION: Contractor �_. . r• 4� <br /> Type of Pump <br /> PUMP.REPLACEMENT: / / State W rk Done <br /> IY e ktjx <br /> f ;��•ci�. ' y-r' '� �:'.��.. ,R i _ ;fir- .. ych�e <br /> PUNP'REPAIE / / State Work boner Aj�.r .Ju E <br /> DESTRUCTION OF WELL: Well Diameter. �` Approximate Depth <br /> Describe Material. and Procedure ` h <br /> I hereby agree to comply with all laws and regulations of. the San Joaquin Local wealth DiLt:rict'. <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN'DAYS *y <br /> after. completion:of my work on a new well, I will furnish the San Joaquin Local Health District a-, <br /> WELI:'DRILLERS'RE;'QRT h :.i V <br /> i the well Lud notify them before putting the cell it use.. The above <br /> information-is true to the est of my knowledge and belief. r1 <br /> �7,. J 3 : <br /> SIGNED TXTLE '1/ ' <br /> (DRAW PLOT PLAN ON REVERSE'SIDE `. i` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .z. <br /> APPLICATION ACCEPTED .By - -_- _-_-- - _ DATE <br /> ADDITIONAL.COMMENTS: <br /> PHASE xI GROUT INSPECTION T' PHASE IIx FINAL INSPEC'iION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � r <br /> E H 1426 4/72 IM ` <br /> f <br /> I <br /> �^ Y <br />