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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FO :bFFI,CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '! Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S LIDO � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued J/-) -2 <br /> '. (Complete In Triplicate) 11. <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct <br /> and/or install the work herein .described. This application is made in compliance with San Joaquin' <br /> County _Ordinance No. 1662 and the Rules and Regulations of the San -Joaquin Local Health District, <br /> CC 11, <br /> JOB ADDRESS/LOCATION r 1 j, OF, A0-•u Lo Ives+ FeowZA6F �D CENSUS TRACT <br /> Owner's Name Phone 3_.Y 2M <br /> IL <br /> _ 3 city <br /> Address <br /> San Joaquin Pump Co. <br /> Contractor's Name (�ixisian Q{Son baguin_Sulphur CaJ License. # Phone ,?04V71 <br /> -- t N�:Sacramento St.., <br /> Lodi, Ca.iarena. 1)&mr <br /> TYPE OF WORK (Check) 6. NEW WELL /-7 DEEPEN _/� RECONDITION /-7 DESTRUCTION /7 <br /> . PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other /r/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �, .1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL � CONSTRUCTION SPECIFICATIONS � <br /> Industrial y. Cable Tool Dia. of Well Excavation 7 <br /> Domestic/private .Drilled _- .Dia.--of-Well-Casing--- T , <br /> Domestic/public ;I <br /> 'Driven '` Gauge -of"Casir:g <br /> Irrigation !I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type;of` Grout T� <br /> Disposal ...r Other O.ther`.;Information <br /> . Geophysical Surface .Seal Installed By: . . . ., <br /> PUMP INSTALLATION: Contractor <br /> a <br /> Type .of Pump R.P. p <br /> PUMP REPLACEMENT: . State Work Done ° 1 A.) T �I <br /> _ _. ,_ ice' «.. d .. ..• a ' �- 3 .... ,; � :- <br /> PUMP .REPAIR: / / State Work Done l ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 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 California pertaining to or regulating welrl `const:ruction. Within FIFTEEN DAYS <br /> 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 these before putting the..well. in.use.... The above <br /> information is true to thi6,best of- my..knowledge andlbelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN PECTION, Son Joaquin Pump Co. i <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE in Sulphur Co.? i <br /> cramento St. <br /> !; FOR DEPARTMENT USE ONLY Lodi, Colftrnia 952 <br /> PHASE I. <br /> APPLICATION ACCEPTED BY '. DATE 4 71 <br /> ADDITIONAL COMMENTS: _T <br /> PHASE II GROUT INSPECTION PHASE III/F11RAL INSPECTTAN } <br /> INSPECTION BY DATE INSPECTION BY DATE r <br /> E H 1426 Rev. 1-74; _!x/75 _.2M <br />