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1r7 <br /> h <br /> SAN JOAQUIN LOCAL ILEALTIi DISTRICT <br /> 70E -`!':'LCF USE: 1,601 E. Hazelton Ave. , St-1-ton, Calif, <br /> Telephone: (209) 4uu-6781 <br /> APPLICATION FOR WELL CONSTRUCT.Otl OR Pl1MI' 1'!'R.^ti'C PerUlt No. <br /> THIS PERMIT EXPIRES 1 Y)AR. FROM DATE ISSUED Date Issued <br /> i _ <br /> (Complete in Triplicate) <br /> I Applic-tion 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 Lompli..ace with San Joaquin <br /> County Ordinance No. 1862 and the Rules ani Regulations of the San Juaqu.a Local Health District. <br /> JOB ADDRESS;:,r,CATION 4e. eL4 Ir .0 �YN�✓,P <br /> CENSUS TRACT <br /> yOwner's NameT Phrine <br /> I <br /> Address �D � �/�t v�C O�r'�d� • ci�, �l 1. / � �_ <br /> Contractor's Name Licensc fl &2373 Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DE :'i RUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMPiti:PI P CF.MEIvT Q � <br /> Other / / <br /> DISTA:,C;E TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY __ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE LO ESTIC WELL — PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia, of Well Excavation <br /> _ X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> irrigation C <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> .!ophysical Surface Seal Installed By: <br /> PUMP I`+STALLATION: Contractor <br /> Type of Pump Sia 6/�Cr`�i � H.P. <br /> 3 - <br /> .1 PUMP f ::PLACEMENT: State Work Done /d iJ ���m --- / \ <br /> PUMP 1_ i'AIR: State Work Done <br /> 4 DES TRU`.TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I here.,y agree to comply with ali laws and regulations of the San Joaquin Local Health District <br /> and the St o lifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> y ' after o let on o my work on a new well, I will furnish the San Joaquin Local health District a <br /> Wr-LL D! LLI-- S REPOT of the wel an ify them before putting the well in use. The above <br /> infor tion is ie a t be - n e ge an3'trelief. I WILL CALL "0 GROUT INSPECTION <br /> PklU :v G C D A IO <br /> SIGN _ TI'T'LE <br /> _ DRAW PLOT PLAN ON REVERSE SID ') <br /> FOR DEPARTMENT USE ONLY <br /> P"S E — - ---- <br /> TPPLIC.-TION ACCEPTED BY <br /> ADDITTuaAL COMMENTS: DATE L <br /> '" --• - <br /> PHASE II 001;7 INSPFCTION <br /> PHASE III/FINAL. INSPECTIO•�N-� <br /> - -- - N 1i DATE <br /> _.._ <br />