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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: �/ 1601 E. azelton <br /> A(209)SCalif. <br /> 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 37 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J-14-2f <br /> (Complete In Triplicate) <br /> Application is''$ereby 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 No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATION �3 ROO CENSUS TRACT <br /> Phone 36f 6�9 . <br /> Owner's Name <br /> Ate_ ,Q p <br /> City <br /> ; <br /> Address <br /> Contractor's Name �-p " Qs � oa-'tom'�"" License !t 3 X903 Phone <br /> DESTRUCTION <br /> TYPE OF WORK (Check): NEW WELL / /,DEEPEN <br /> RECONDITION /� <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT %I <br /> Other d / W <br /> j DISTANCE TO NEAREST: SEPTIC!TANK SEWER LINES PIT PRIVY <br /> I SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTBER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF.WELL ;CONSTRUCTION SPECIFICATIONS <br /> ' -Industrial - �- - Cabie�Too-1 —Dia—of Weli-Excavation- <br /> Drilled Dia. of Well CasingJ. - � <br /> Domestic/private �_. ..Gauge of Casing = <br /> - Domestic/public - Driven - gp <br /> Irrigation R, --_Gravel-Pack ^epth-o f- Grout-Seai.: <br /> Cathodic Protection Rotary ---Type'of' Grout <br /> Disposal —Other Other Information <br /> Geophysical f r" y Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H <br /> 1 ` T9pefof Pump T° <br /> Il � <br /> PUMP REPLACEMENT: `State Work Done pwrf <br /> _ State Work .Do - - - - <br /> i PUMP �.REPAIR:y /_7 _ . ..�: - _ <br /> I DESTRUCTION OF WELL: Well Diameter W& Q lzeb Approximate Depth'�„T;;, <br /> �cr <br /> Describe Material and Procedure <br /> al Health istrlct <br /> I hereby agree to comply with all' laws and regulations of-the San Joaquin Loc ` <br /> and the State of California-pertaining to or;regulating well construction: Within FIFTEEN DAYS <br /> ! I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new well, <br /> them before putting the well in use. The above <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to.-the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> PRIOR TO GRQJJTING ANDA F, NAL 'INSPECTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEP Mr.clt u�t ONLY r-7 <br /> PHASE I 1 �; �P DATE t� <br /> APPLICATION ACCEPTED BY- 4 ` °C't <br /> ADDITIONAL COMMENTS: c[- ' PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 6-tf 1177 ,- 214 <br /> �, , Ii.ec oo.. 1_74 <br />