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SAN'JOAQUIN LOCAL 11FALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave. ., 'Stockto.:., Calif. <br /> Telephone : (209).'466` 6781 <br /> PLICATION FOR WELL CONSTRLCTION'.OR PUMP PER141T Permit No. 7 2-- X a <br /> THIS PERMIT :EXPIRFS . 1 YEAR-FROr1 DATE ISSUED Date'Issued D ' 7 7z- <br /> '(Complete Iii 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 Joaqui <br /> County Ordinance No.-1862 and the Rules and� Regulations -of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � 4z CENSUS-TRACT <br /> Owner's Name ': 1��d61% r : rs it Phone <br /> Address /1�'7� S _ LCJ 4A k2 b,i 4� City - 0-e <br /> Contractor's Name License # hone ?b 7G <br /> IV <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PL`MP REPAIR REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> , .Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - C Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> R <br /> PUMP INSTALLATION: Contractor tJ e.e. • 42 <br /> Type of Pump H.P. 6 D 4& <br /> 10, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done �a n <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the-well i us The above <br /> information is true to the best of my knowledge and belief, <br /> SIGNED Vp TITLE <br /> (DRAW PLOT PLAN ON' REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/y-� �'K_V `-� DATE 7 �— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTIO' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . WO <br /> E H 1426 4/72 1M <br />