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"EU/S �1 ;;r ; <br /> 16;,1fii . Aphone: (209) 466-6781 <br /> APPLI ION FOR WELL CONSTRUCTION OR PUMP --RMITPermit Pio.THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date I:sued � 7L <br /> otrplete In Triplicate) <br /> pp ,:ation 1.9 hereby made to the San Joaquin Local Health District for a permit to const.,::.0 <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 o! the Sen Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name / <br /> Phone <br /> Address 3 �- <br /> 3 � Cts« <� city <br /> 5ZI,r,-LLL-^ <br /> Contractor's Name <br /> License <br /> Phone <br /> C 5"7 <br /> TYPE OF WORK (Check): NEW WELL / DFEPpr� — RECONDITIJN /-7 DESTRUCTION /-7 "V <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PU?* P1,AC <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TAt-'K T <br /> SEWER LINES PI, .'RIVY <br /> SEWAGE DISPOgAL FIELD /49014 CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE QF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ofWell Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> t/Dome8tic/public Driven Gauge of Casing , <br /> Irrigation Gr-vel Pack Depth of Grout Sea 1 �a, <br /> Other Rotary Type of Grout _-S <br /> Other1'— <br /> Other In:ormation <br /> PUMP INSTALLATION: Contractor <br /> Tyre of Pump �'; ` - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP RI'PAIR: / 1 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agre comply with all laws and regulations of the San Joaquin Loca: Health District <br /> and th ate of Ca ornia pert ing or regulating well construction. Within FIFTEEN DAYS <br /> after,.completion of m work on new ell, I will furn•sh the San Joaquin Local Health District a <br /> WELL D�ILLERS PORT the we a no them before patting the well. in use. The above <br /> inform tion :s true the es ' f y k�"Wledge and belie <br /> SIGNED C L�_._ <br /> ` TITLE ,+ <br /> DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTYXNT USE ONLY�. <br /> APPLICATION ACCEPTED BY DATE <br /> G•��r C /� FF <br /> ADDITIONAL COMMENTS: _ <br /> �' • /�(-�"� lc;_ �,f ) ,J• •5.• L <br /> PHASE II GROUT INSPECTION PHASE- III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �(!-, DATE <br /> CALL I.OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 7/72 1M <br />