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} <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.',: Stocktor,, Calif. <br /> 1. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE 'ISSUED Date: Issued S' 7Z <br /> (Complete In Triplicate) <br /> Application is _hereby m de,.to the SangJoaquin Local Health District for a permit to cons ruct <br /> and/or install the`work; herein described. Thi's application is made in compliance with San Joaquin <br /> County Ordinance No. 1$_62�and the. Rules- and Regulations of the San Joaquin Local Health District. <br /> �p�( COY`-� , f <br /> JOB ADDRESS/LOCATION • CENSUS TRACT_ <br /> Owner's Name` . Phone (� <br /> City czf� L. <br /> Address /`a -- <br /> Contractor's Name 2 License # Phone Z <br /> .i <br /> 4 <br /> TYPE OF WORK (Check) : "NEW WELL/ / DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> 'PUMP INSTALLATION / / PUMP REPAIR X1 PUMP REPLACEMENT /? <br /> ,Other <br /> -�1 <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �Ft <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE '` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ADri <br /> bl Tool Dia. of Well Excavation <br /> Domestic/private:` led Dia. of Well Casing <br /> Domestic/public " ven Gauge of Casing <br /> Irrigation ; avel Pack Depth of Grout Seal <br /> Other tary Type of Grout <br /> her Other Information <br /> PUMP INSTALLATION: ;; Contractor <br /> jType of Pump H.P. <br /> I� <br /> PUMP REPLACEMENT: State Work Done <br /> i; <br /> PUMP REPAIR: State. Work Dane <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is rue to;the <br /> est of my k dge a elief. <br /> SIGNED TITLE -�- <br /> I DRAW PLOT PLAN ON R RSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. DATE �l <br /> ADDITIONAL COMMENTS: '- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL IN <br /> INSPECTION BY .1 DATE INSPECTION BY SATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br /> f <br />