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SAN JOAQUIN LOCAL HEAL 'H DISTRICT W <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , St�)ckton, Calif. <br /> Telephone : (209) 461-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��1��5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedv2—e,21-71 <br /> Application is hereby made to the San (Joaquin eTriplicate) <br /> for aermit to construct <br /> P t uct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 186,��nd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/I4WAq+ 1 j Ar. �t�� Gr CENSUS TRACT <br /> fI <br /> Owner's Name s' Phone <br /> Address <br /> City <br /> 4 <br /> Contractor's Name y, l�'Z �" License vphone <br /> i <br /> TYPE OF WORK (Check) NEW WELL K, DEEPEN /% RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP_REPAIR. / I, PUMR.-REPLACEMENT -/?7 <br /> DISTANCE TO NEAREST: SEPTIC TANK1& -i-SEWER LINES VP 97 I-PIT 'PRIVY <br /> SEWAGE DISPOS � FIELD CESSPOOL/SEEPAGEP_TT OTHER <br /> ^- `PROPERTY-LINY - PRIVATE DOMF'STIC WEL_�� P-UBLIC 'DOMFSTIC�WELL 4 <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toolf Dia, of Well Excavation �'/ ' <br /> Domestic/private gilled'.' 1 ",' Dia of-Well Casting � � ✓%___ <br /> Domestic/public Driven`� r- Gauge -oft Casing Z <br /> Irrigation Gravel Pack Depthiof�Grout Seal: — ¢- <br /> Cathodic Protection Rotary Type of.•Graut <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -00 A0,V _r <br /> Type of Pump i H.P. <br /> . � <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work .Done` <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and-,P-r.ocedur-ems.-.- _ T -=-m <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 weld. construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a ' <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED <br /> (. GJ PL T PL ON REVERSE SIDE) <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: (�A� <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY r.► , DATE INSPECTION BY DATE <br /> y fi 7� C\q <br /> - E_H-.1426 / Rev. ,.1 74 . y 0�%7 2M <br />