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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltori4A,'�0-.",:g't.ocktoi,,,, <br /> Calif. <br /> Telephone- <'>:(2`09)`4.460;-6781 <br /> PLICATION FOR WELL PUMP PERMIT <br /> Permit No, <br /> THIS PERMIT"'EXP!.RES.-Z1 I YEAJOFROK.-.;DATE-)IS SUEV.- TODate`,Igi5ued <br /> Applicati,ot5.ib!;herebylimade'i,to' thervSa Jbaq n <br /> 11-� uintt;OLAl 11&al�h Distriictlf'- <br /> o rtr5 a8 p r -)to.� c6� st_tjiCj <br /> and/or install .the work herein described. Thl hwaPp-iic;a:t!:6n`v• made T iti"!,compliance= with.aSan tGOaquii <br /> County3prdinaficeoNo,.,c4and>'ReguS-Aft:'Joaquin_Lotal. �Health�Di8tiict'. <br /> '7 P,v P k,I 'U C,1 r.;"r <br /> T'�4 0 fW L - <br /> I;qq ?a <br /> JOB ADDRESS/LOCATION b, (,CENSUS;.;TRACT' <br /> f17- <br /> rA_ <br /> Owner! <br /> �:l v�-,vi C;-�v q. -_`A--_Phonti, <br /> _c 5_ <br /> Address <br /> Contractor's Name gxr:: License # Phone <br /> 40 <br /> TYPE OF WORK (Che DEEPEN RECONDITION DESTRUCTION /_7 - <br /> :h INSTALLATION --PUMP -REPLACEMEN7T-- /_7 <br /> PUMP - ALLATION PUMP REPAIR <br /> DISTANCE TO NEA -SEPTIC; TANK­ <br /> _5b SEWER LINES I JV PIT PRIVY <br /> .�SEWAGE:.DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT. OTHER <br /> INTENDED'USE ' - -I TYPE OF'WELL, CONSTRUCTION- SPECIFICATIONS <br /> _Cable tool Dia. .of Well. Excavation TO <br /> Domestic/private': - <br /> X Drilled Dia'. of Well Casing f <br /> .' Do i ' ' ' . .: <br /> 1pesticbubl­Ic Gauge' of Cd <br /> sing <br /> .-DZ�pth of, Grqut� Seal—w— <br /> Trr <br /> igation <br /> OtherRotary Type 'of Grout <br /> I Other Other. Inf o"rmatioh` <br /> PUMP 'INSTALLATION C6i /rMA M4 A <br /> -5Type. .of Pump <br /> 2 H.P.- <br /> PUMP REPLACE-MENT: State Work Done <br /> REPAIR: State Work Done <br /> DESTRUCTION OF WELL: aWell .Diameter <br /> Approximate--Depth <br /> jDescribe Material 'and Procedure <br /> I hereby agree to comply with.all Taws and regulations of the San Joaquin Local Health District <br /> and ;1the State of. Califo::�rnia pertaining to or regulating well construction. : Within FIFTEEN DAYSafter complet r ioii. of my�� ­i7k' bu a new we <br /> off' <br /> 11, 1 will furnish the San Joaquin Local Health Distric't a <br /> WELLDRILLERV REPORT o� the well and notify them before putting the well in use. The. above <br /> S true t <br /> rue o e <br /> fthe best :knowledge and belief.' <br /> SIGNED f <br /> TITLE <br /> 0 (DRAW PLOT PLAN ON REVERSE' SIDE)-. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY., <br /> -62.A <br /> ADDITIONAL COMMENTS:" ' 11 DATE <br /> PHASE II- GROUT INSPECTION PHASE <br /> INSPECTION BY ;�;X-JEINAL INSPECTION <br /> DATE T E INSPECT-. <br /> DATE <br /> GALL FOR A GROUT INS <br /> 99TIPqpl�IPR.JO GROUTING,AND FINAL INSPECTION,____ <br /> E H 1426 — :__Qd�I;' <br /> 4/72 1� <br />