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J DISTRICT <br /> UIN LOCAL HEALTH Calif <br /> SAN JOAQ Stockton, <br /> E, Hazelton Ave. 466-6781 IT Permit No• 1�-- <br /> } 1601 : (209) OR PUMP PERM <br /> -OFFICE USE: TelephoneCONSTRUCTION <br /> WELL Date Issue.d <br /> E j APPLICATION FOR -ISSUED <br /> l REAR FROM DP cgnstruct <br /> P , MI`s BXpIRES Triplicate) fox a permit to San.S'oaquin <br /> [ THIS (Complete In District liance with <br /> Local Health in comp Health District. <br /> San Joaquin application is made Joaquin Local. <br /> ` made to the .This aPP Jaaq <br /> is hereby described. Mations of the, San # <br /> iPPlication work herein the Rules and Reg .. rl. CENSUS TRACT <br /> and/or install the • ,.1862' and <br /> Ordinance 6 <br /> �CountY Phone <br /> JOB ADDRESS,I � ,� <br /> R _ City <br /> s Name <br /> Owner hone <br /> • __ . .., -. � a Ak License <br /> Address 6r <br /> �. <br /> tor' s Name UCTXON-� <br /> ContracQ <br /> DESTR � <br /> DEEP I RRCOND", I p� REPLACEMENT I <br /> y. NEW WELL DE PUMP REPAIR I <br /> WOgK (Check) ' PUMP INSTALLATION <br /> 1 TYPE OF <br /> 0 e PIT PRIVY - OTHER��_- <br /> SEWER LINES Z© /�f <br /> 1 IC TANK ID CES5POOL(S�AGE LIC D'TSTIC WELL <br /> REST: SEPT FIELD PUB <br /> DISTANCE TO NEA SEWAGE DISPOSAT�.y STIC WELL --� SPECIFICATIONS <br /> fb PRIVATE DOME CONSTRUCTION <br /> PROPERTY LINL� WELL of Well Excavation <br /> TYPE OF Dia. . <br /> INTENDED USE Cable Dia. of Wel.i- Casing �l. . <br /> Industrial Drilled �� Gauge of Casing <br /> ti( <br /> Domestic�Private Driven '. �' h of Grout Seal <br /> --tx Pack Dep <br /> Domestic/Public -� r Gravel _ Type of Grout <br /> Irrigation y Rotary Other Information <br /> Cathodic Protection -- — Other ------ --- Surface Seal Installed B <br /> _ - <br /> Disposal ^ <br /> s r—Geophysical. <br /> a Contractor <br /> PUMP INSTALLATION Type of Pump <br /> 4 <br /> State Work Done v <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> t PUMP .REFAYR: Approximate Depth ____ <br /> Well Diameter <br /> DESTRUCTION OF WELL. Describe Material and Procedure <br /> 4Within FIFTEEN I <br /> i <br /> laws and regulations of the anJoauin Local Health Dist <br /> agree to comply with all 1 Mating well construction <br /> I hereby g pe rtaining to or reg Joaquin Local Health Drs <br /> I will furnish the Sanhll in use. The above <br /> and the State of of my work on a new well , them before putting GROUT INSPFsC' <br /> ' after completion of my <br /> knowledge and belx.ef • I WILL CALL FOR A <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the best of mY <br /> . PRIOR TO GROUTING AND A FINAL INSPECTIO LE <br /> REVERSE SIDE) <br /> SIGNED Ld PLO <br /> FOR DEP AR NT USE ONLY <br /> i DATE <br /> PHASE I <br /> ' App ICATION ACCEPTED By P SE III AL INSPECTION <br /> ADDITIONAL COMMENTS! DATE <br /> k P I UT INSPECTION �g II3SPF.CTION BY <br /> DATE <br /> i INSPECTION BY y <br /> 7--74 <br />