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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. Hazelton Ave. , Stockton, <br /> Calif <br /> FOF: OFFICE USE: Telephone : (2a9) 466-6781 <br /> PUMP PERMIT Permit Na. <br /> APPLICATION FOR WELL• CONSTRUCTION OR <br /> THIS:PERMIT EXPIRES 1 YEAR FROM DATE I5_ SHED <br /> Date Issued , r 3� -�' i <br /> i (Complete In Triplicate) <br /> tealth <br /> rict <br /> a permit <br /> o constrct <br /> Application is made to the San Joaquin I,oca1liication istrt <br /> made inconpliancewith .SanuJoaquin <br /> and/or install the work herein descried. This app <br /> Count Ordinance No. 1862 and the. Rules and Regulatans of the San Joaquin Local Health District <br /> County ENSUS .TRACT <br /> jjj <br /> JOB ADDRESS/� <br /> Phone <br /> Owner's Name 9Lt <br /> . ..� - .- .. City <br /> Address <br /> hane <br /> OW <br /> Contractor' s Name 101Y <br /> �e License P <br /> PE OF WORK {Check} : NEW WELL I I DEEPEN '/ <br /> REPAIR PUMP REPLACEMENT <br /> / . RECONDITION / DESTRUCTION <br /> TY PUMP INSTALLATION >�` / I I7 <br /> Other / / -- O <br /> LINES PIT PRIVY <br /> _ <br /> C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER CESSPOOL/SEEPAGE PTT OTHER <br /> M SEWAGE DISPOSAL FIELD TPUBIIC_U(?MESTIC WELL <br /> PROPERTY .LINE. ---PRIVATE .DOMESTIC-WEI.LCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL .� C <br /> Cable Tool Dia.,,of Well Excavation ___- , <br /> Industrial C <br /> � --• � Drilled Dia.,,of Well Casing � <br /> Domestic/private Gauge 6f'-Casing _ <br /> ' Domestic/public Driven .� <br /> .` Gravel Pack -Depth of Grout Seal ---� <br /> Irrigation .: - -- --- <br /> k s Type of Grout flJ <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other ? <br /> —Surface Seal Installed By: <br /> Geophysical <br /> Contractor _ <br /> PUMP <br /> INSTALLATION; � _ � �� R.P. _- <br /> Type-of-Pump ^ <br /> PUMP_REPLACEMENT: / / ` State Work T3one <br /> PUMP .REPATR: <br /> State Work Done <br /> I I - / <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with 1 lavas and regulatio s of the S Joaqui L c 1 Health District <br /> and the State of California pertaining to or regulating wdll "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 knowle ge and belief. I WILL CALL FO A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIU TITLE <br /> SIGNED <br /> PL L '"ON REVERSE SI E) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I DATE 3' 3•7� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p I/ NAL INSPECTIO <br /> PHAS I GROUT INSPECTION ATE <br /> INSPECTION BY DATE INSPECTION BY <br /> 6/77 _ 2M <br /> P 14 11496 Rev- 1-74 __ <br />