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� / SAN•JOAQUIN LOCAL HEALTH DISTRICT r V f <br /> % OFFICE USE: Z, 16D1 E. Hazelton Ave. , Stockton, Calif. <br /> " Telephones (209),:`466--6781,. <br /> 1 APPLICATION FOR WELL'CONSTRUCTTON, OR PUMP PERMIT Permit No. ' <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued.Z �7 76 <br /> (Complete In Triplicate) <br /> Application is hereby¢riiade to the San Joaquin Local Health District fora permit to..conetruct <br /> ti and/or .install the work herein described. This application is 'made in eompliance with, San Joaquin <br /> County Ordinencc •No. '1862 and 'the Rules. and Regulations of the' 8an :?oaquiil,;Local Health District. „ <br /> :. +riPs� °FiPa v-ro C.C se a , Hwy 4 9 - .uc,z.r W OF PEc r0 4 <br /> JOB ADDRESS/LOCATION &vo_ tloujE ryes-{ 0 F LAk,r-*GE r2U SJOE C44A*vXENSt3§ TRA' <br /> Owner's NameY !�n o C 2 V2u 5�y L_ <br /> Phone- <br /> Address =. . / L/)i jQ,,0A - R D City.-:, A c lqpa <br />` <br /> Contractor's Name on Joaquin SJuin Pump Co. License # 3 10-37k Phone -3694M1-3694M7 <br /> ­z; (Division-o an oaq - <br />' �o sfa 95240 <br /> TYPE OF ,WORK (Check) . NEW f I,, DEEPEN,j 7 RECONDITION /_7 DESTRUCTION /-f <br /> PUMP INSTALLATION J JJ PUMP REPAIR /�J PUMP REPLACEMENT <br /> Other <br /> E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r ; <br /> ` PROPERTY -LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial "r Cable Tool Dia. of Well Excavation <br /> Domestic/Private Drilled-. Dia. of Well -Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f Gravel Pack- Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout e <br /> Disposal Other w Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Cointractor <br /> Type .of Pump ; , H.P. <br /> PUMP REPLACEMENT: • J� State Work Done <br /> PUMP '.REPAIR:� `~ / / ate ork Don <br /> DESTRUCTION OF WELL: —Well Diameter . - Approximate Depth. <br /> DescriW'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 Cal;i<forni& pertaining.to or. regulating well construction. Within FIFTEEN DAYS <br /> F 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 true to the-best-of..my,.knowledge and belief_ . I WILL CALL FORA GROUT INSPECTION' <br /> PRIOR TO GROUTING 'AND A FINAL INSPE ION. <br /> -- TITLE San Joaquin Pump Co. <br /> SIGNED ` <br /> DRAW PLOT PLAN ON REVERSE SIDE Divsion of San Joaquin SulphurCo.) <br /> FOR DEPARTMENT USE ONLY '^ i adi, Caoifarnica 95240. . <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE •-2G - <br /> "ADDITIONAL COMMENTS: .,. <br /> PHASE II GROUT INSPECTION PHASE ,III FINAL INSPECTI N <br /> E INSPECTION BY DATE INSPECTION BY DATE /6 ?` <br /> V75 2M <br /> P #4 1426Rav_ 7-7G <br />