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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> F0 OFFICE USE: I <br /> •: Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1' <br /> t <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /' <br />� I <br /> (Complete In Triplicate) <br />` Application is her eby :made to the San Joaquin Local Health District for a permit to constrn, Joauin <br /> uct <br /> is E and/or install the work herein described. This applicatons ion the San eJoaquinin pLocal eHealth with SDistrict. <br /> County Ordinance No. : 862 and the. Rules. and, Regula . <br /> I r �Cspt-ipCENSUS TRACT <br /> JOB ADDRESS/LOCATION WAST CCI 'd ei� Tn � <br /> Phone -_ <br /> Owner's Name ' <br /> City <br /> Address <br /> Sam 1004nin Pump Co. License # 3/0378 ?hone <br /> Contractor' s 'Name • • '' ' �___ <br /> , i <br /> - ' RECONDITION / / DESTRUCTION <br /> TYPE OF WORK. (Check) ; NEW WELL / / DEEPEN / / p� REPLACEMENT /� <br /> �I PUMP INSTALLATION PUMP REPAIR / - <br /> UBLJ <br /> �; Other <br /> !` i SEWER LINES PIT PRIVY _ <br /> DISTANCE TO NEAREST:lj SEPTIC TANK OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> I PROPERTY LINE - PRIVATE. DOMESTIC WELL CWE <br /> ONSTRUCTION PUBLIC SPECIFICSTTCATIONS � <br /> INTENDED USE TYPE OF WELL <br /> Industrial 1 Cable Tool Dia. of Well Excavation �_-- <br /> Drilled Dia. of Well Casing <br /> Domestic/priva`te Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> I Irrigation � Gravel Pack p <br /> Cathodic Protection Rotary Type of Grout <br /> Other Other Information <br /> Disposal �I -- <br /> Geo h � Surface Seal-Installed <br /> sical B ; <br /> P y. .0 <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: /Mate Work Done <br /> a <br /> F <br /> PUMP -`REPAIR: /State Work-Done - <br /> ';. Approximate Depth <br /> t DES•TRUCTION� OF WELL: Well Diameter <br /> �i Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I will furnish the San Joaquin Local Health District <br /> after completion of my work on anew well, <br /> WELL DRILLERS REPORT of the well and not them before putting; the well in use.. The above <br /> information is true to the best of my know rump and belief. I WILL CALL FOR A GROUT INSPECTION <br /> INAL..I SP an .oaqum 'ump o. <br /> PRIOR TO GROUTING TITLE (Division of San Joaquin Sulphur W <br /> ! SIGNED i acromento t, <br /> 11 (D P OT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> ' PHASE I �� <br /> DATE Z <br /> APPLICATION ACCEPTED :BYADDITIONAL COMMENTS: p ,5 l/FI INSPECTION <br /> 1'HASE�. IIGROUT INSPECTION ATE <br /> ,INSPECTIONAY II DATE INSPECTION <br /> I�' �� o/77 2M <br /> u 11�9r, ua�r_ . 1-74 __ <br />